Public Health

– in the Scottish Parliament at 2:40 pm on 1st September 1999.

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Photo of Lord David Steel Lord David Steel Presiding Officer, Scottish Parliament 2:40 pm, 1st September 1999

The next item of business is the debate on motion S1M-105 in the name of Susan Deacon, on the promotion of public health, and an amendment to that motion in the name of Mary Scanlon. Members who wish to speak in this debate might care to press their buttons now.

Photo of Susan Deacon Susan Deacon Labour 3:11 pm, 1st September 1999

Thank you, Presiding Officer. Just under two years ago, the Scottish people voted overwhelmingly for this, their first ever democratically elected Scottish Parliament, a Parliament that they wanted to deliver a better quality of life and better opportunities for the people of Scotland-in short, a Parliament that would make a difference.

The 129 members of this Parliament now have a historic opportunity and, I would argue, a responsibility to realise these aspirations and to use the powers vested in us to make a real improvement to the lives of those we represent. Nowhere can we better demonstrate our willingness and our capacity to do that than in the fight to improve the health of the Scottish people. That is why today, on this the first day of our first full parliamentary session, I ask members to avoid the distractions and to unite with me to signal our determination to tackle the root causes of ill health in our country and to work together to build a healthier Scotland.

Good health is not just about having a good health service. Of course we must constantly work to improve the NHS-we are doing that-but a healthy Scotland does not just cure ill health, it prevents it from happening in the first place. For too long, Scotland has been branded the sick man of Europe. We now have a chance to change that.

In February, Donald Dewar, in his previous incarnation as Secretary of State for Scotland, joined other Scottish Office ministers in setting out the white paper, "Towards a Healthier Scotland". It was the product of widespread consultation. It built a consensus around a comprehensive strategy for improving the health of the Scottish people. The task now falls to us to translate the ideas of that white paper into action. Today I ask members of the Scottish Parliament, wherever they sit in this chamber, to endorse the principles set out in the white paper and to give their backing to me and to the Scottish Executive to take forward its implementation.

This is not a single issue with a single policy solution or one quick-fix remedy. No one piece of legislation or one investment will make a difference. We need a comprehensive, cross-cutting approach that reaches deep into our policies and practices and into our culture and attitudes. The white paper sets out a shared vision of a healthier Scotland. It recognises that good health is about more than not being ill. It recognises that we can tackle ill health only through a sustained attack on inequality, social exclusion and poverty, and that we need to address questions of lifestyle and of life circumstances.

Let me remind members that for 18 long years in this country we had a Government that refused to recognise that ill health was linked to poverty. We recognise that connection and we are prepared to act on it.

Photo of Phil Gallie Phil Gallie Conservative

Does the minister agree that, in the period that she refers to, the previous Government increased expenditure on health year on year to an extent that Labour has not yet equalled?

Photo of Susan Deacon Susan Deacon Labour

I refuse to take lectures from Mr Gallie or from any other members of his party on what is best for the health of the people of Scotland.

Photo of Susan Deacon Susan Deacon Labour

For 18 years we saw the Government point the finger at the Scottish people.

Photo of Phil Gallie Phil Gallie Conservative

Answer the question. The minister does not know the answer.

Photo of Susan Deacon Susan Deacon Labour

The Government told the Scottish people that ill health was their fault.

Photo of Susan Deacon Susan Deacon Labour

We say that ill health is a responsibility for Government to address. Unlike the Conservatives, this Government is addressing it, and I challenge Conservative members to join us in doing that.

Photo of Phil Gallie Phil Gallie Conservative

She has failed to answer the question.

Photo of Susan Deacon Susan Deacon Labour

We will give the Conservatives a second chance. They did not do it in government; they can do it now.

Across the Scottish Executive, we are taking action to make real improvements to people's lives through better job prospects, better housing and better education. We will work towards a sustainable environment and economic improvement. We will work in all those areas to achieve sustainable improvement in health.

The white paper sets out the strategy for this approach: first, a concerted attack on health inequalities; secondly, focused measures to improve the health of children and young people; and thirdly, a series of major initiatives to prevent Scotland's big three killers-cancer, strokes and coronary heart disease, which together account for a quarter of all deaths.

Within that framework, the white paper sets out detailed, practical proposals for action on seven priority areas: child health, coronary heart disease, cancer, dental and oral health, sexual health-in particular teenage pregnancies-mental health and accidents and safety. I ask for members' backing and involvement to prioritise these measures, based on the principles in the white paper and on the commitments that the Executive set out in the partnership agreement.

The issue of public health cuts across party divides and geographical boundaries, but let us make no mistake: it is by no means a terrain devoid of controversy. If new politics means anything, it must be about our capacity to come together, address these difficult questions and come up with the brave, imaginative solutions that are needed to make a real impact.

I wish to illustrate a few of the challenges that we face. Scotland has one of the highest rates of teenage pregnancy in western Europe. Last year, more than 9,000 girls in Scotland under the age of 20 became pregnant. More than 4,000 faced the trauma of termination. More than 2,000 cases of sexually transmitted infection were reported in young women aged between 15 and 19. We owe it to our young people to tackle this issue with determination and innovation and to match that with feeling, understanding and care.

Photo of Fiona McLeod Fiona McLeod Scottish National Party

Can Ms Deacon explain how we will educate our young people about sexually transmitted diseases and teenage pregnancies when, in the next three years, the Health Education Board for Scotland budget will be frozen in real terms?

Photo of Susan Deacon Susan Deacon Labour

The emphasis that has been put on sex education shows its importance. I will say more about that in a minute.

We are investing additional money in health promotion activities across the board. As I will mention in a moment, that is building on the work that HEBS is doing and also-crucially-on the work that local health promotion units are doing in health boards. I remind members that the health service and local health boards are experiencing record levels of growth. That is an important backdrop to our policies.

If I may return to the general point-

Photo of Susan Deacon Susan Deacon Labour

I would like to cover some other points and will not take another intervention at this stage.

I know that contraception and sex education are sensitive issues, and that people have deeply held opinions on such questions, but if we are to make a difference we have to be mature enough, as politicians and as a country, to discuss them openly and honestly.

Despite many attempts to improve oral hygiene, our children still have an appalling record of tooth decay. The pain, distress and disfigurement are real. In Glasgow, for example, the most common reason for children under 10 being given a general anaesthetic is tooth extraction. The poorest 10 per cent of children in Scotland suffer 50 per cent of the dental decay. That is unacceptable. A generation has passed by since Scotland last addressed the question of the fluoridation of public water supplies. We owe it to the Scottish people and to our children to reopen that debate in a spirit of open consultation that is based on the facts.

Smoking is a similar issue. We all agree that a reduction in smoking and passive smoking will reduce the incidence of coronary heart disease, lung cancer and strokes. Let us be straight: no other single lifestyle change could do more to improve our health as a nation, but how far do we want to go? How do we best reduce the risk and provide support both for smokers and non-smokers? I may not agree with everything that Mr Henry, the member for Paisley South, has had to say about smoking but I applaud him for having brought the debate into the public domain.

If we are going to make a real impact on the health of the people of Scotland, that must start right at the beginning: not at birth, but before it. How should we support pregnant women-particularly those in our most deprived communities-and help them to eat better, drink less and stop smoking? All those factors have a direct impact on the health of a baby, continuing into childhood and adulthood.

What else can we do to improve the nourishment of our children and babies? We know that breast-feeding is best for the health of babies and mothers, but the incidence of breast-feeding in Scotland is still among the lowest in Europe. How can we change the culture of our society? How can we help mothers to take up and to continue breast-feeding, should they choose to do so, during those early months? One thing is certain: no one Government diktat or pronouncement will make a difference. We must work together to raise awareness and to foster a change in cultures and attitudes.

Photo of Susan Deacon Susan Deacon Labour

I would like to finish my speech. However, I shall accept a very brief intervention.

Photo of Dennis Canavan Dennis Canavan Independent

A few weeks ago, the minister visited Falkirk royal infirmary. I am grateful for the fact that she notified me so that I could accompany her on her visit-a courtesy that the First Minister and some of his ministerial colleagues unfortunately do not follow.

The minister may be aware that, since her visit, there has been concern in the Falkirk area about suggestions-and I put it no stronger than that-that maternity services may be removed from Falkirk royal infirmary. There is a broader concern, throughout Scotland, about a trend that began under the previous Government towards the centralisation of many services, including maternity services. Will the minister take it from me that it would be completely unacceptable to deprive mothers of the right to have their children in Falkirk royal infirmary if that is their wish?

Photo of Susan Deacon Susan Deacon Labour

That was not quite such a brief intervention as I had hoped for. However, I was happy to join Dennis at Falkirk royal infirmary and was pleased that he was there to help me to pull the curtains off the wall while I was unveiling a plaque.

It is for health boards to consider how best to deliver maternity services in their areas. However, I give Dennis Canavan an assurance-with a great deal of conviction and as the mother of a young child-that I want to ensure that throughout Scotland the best possible provision is made for maternity services in every health board area. I want local health boards to make that provision in a process of consultation with the local communities, so that they can come up with the solutions that are right for them.

I shall say more about how we plan to implement our agenda, although I know that I have time today only to touch on a few strands of our plans. First, we must work across traditional boundaries, be they political, sectoral or departmental. I want to remove the bureaucratic barriers to action. I have asked officials in the health department to put our health priorities on a fast track, not just within that department but across a range of policies within the Scottish Executive. That will bring together those at the sharp end to ensure that the drive is in one direction for the benefit of the nation's health.

We must also support those who are working together locally to improve health. The link between health boards and local authorities is central to this programme, and other organisations and agencies in the public, private, voluntary and community sectors will all have a role to play.

I look forward to the Health and Community Care Committee's contribution to grasping the opportunities ahead. The committee has a key role to play in generating innovative and creative solutions and in engaging with a wide range of organisations in the development of ideas and proposals.

A key element of how we get to work on delivering improvements will be our programme of health demonstration projects, which focuses on the health and well-being of children, the sexual health of young people, coronary heart disease and cancer. Some £15 million will be invested to put in place innovative solutions at a local level to provide test beds for action on which we can then build across Scotland.

Another major element of our prevention measures is childhood immunisation. I am particularly pleased to confirm that I will shortly announce details of our new immunisation programme to tackle meningitis C for the benefit of children across Scotland.

We will also shortly be making a series of new appointments, including national co-ordinators for diet and for health demonstration projects, and public health and health promotion professionals to the Convention of Scottish Local Authorities.

As I said, we will work with the Health Education Board for Scotland and with local health board promotion units not only to build on their successes but to examine how we can maximise the impact of our health promotion activities and messages. We are also moving forward in our programme for the development of healthy living centres, aided by lottery funding. The centres will improve health and well-being, focusing in particular on those with the poorest health who are living in our most deprived communities.

The list is by no means exhaustive, but I hope that it serves to demonstrate the commitment and sheer determination with which I, my deputy Iain Gray and the Scottish Executive intend to tackle public health and to improve the health of the people of Scotland.

No one individual, organisation or political party has a monopoly of good ideas-the way in which this Parliament has been designed to operate is a recognition of that fact. I give members an assurance that the Executive will provide the vision, the values and the sheer determination to tackle the root causes of ill health and to lead the drive to improve the health of the Scottish people. I also ask each and every member in this, our new Scottish Parliament, to join us in that task. Together we can build a healthy Scotland.

I move,

That the Parliament agrees the key priority of promoting better health as outlined in the Partnership Agreement; endorses the principles of the White Paper 'Towards a Healthier Scotland' as the foundation for action to improve the health of the people of Scotland, and calls upon the Scottish Executive to work in partnership with relevant organisations to implement measures to achieve this aim.

Photo of Lord David Steel Lord David Steel Presiding Officer, Scottish Parliament

Before I call the Conservative and SNP spokespersons, who will have eight minutes each, I should say that the debate open to the floor will be time-limited to four minutes per speaker. I call Mary Scanlon to move amendment S1M-105.1.

Photo of Mary Scanlon Mary Scanlon Conservative 3:28 pm, 1st September 1999

We all agree in this chamber that promoting better health, improving the people of Scotland's health and working in partnership are key priorities for the Parliament. I was delighted to hear Susan Deacon say that no government diktat will make a difference in that, as that is the background to my amendment. Although the "challenge for individuals . . . who can do so much to improve and safeguard their own health" is briefly mentioned on page 62 of "Towards a Healthier Scotland", I ask her to support my amendment to ensure that we give greater emphasis to individuals taking responsibility for their own health.

The issue was before the public eye last week regarding cervical cancer screening-we discovered that many individuals had been called for a smear test as many as eight times. I would like Susan to use this opportunity not just to set out a framework for public health but to encourage individuals, within this chamber and throughout Scotland, to take greater ownership of their own health. I hope that she will support me in raising the profile of individual responsibility, as is endorsed in the white paper.

A successful project in Finland was based on major lifestyle changes through concerted individual, community and Government action. I ask the minister again to bring the individual into this partnership.

There are many wide-ranging aspects to this debate on public health, and I hope that my colleagues Ben Wallace, Alex Fergusson, David Mundell and David Davidson will have the opportunity to contribute to it.

The white paper on health addresses major areas. It also includes nine specific funding pledges. This comes in a week when an additional £80 million is being given to education from other budgets. I ask the minister to honour those nine funding pledges and to state that there will be no reduction in the health budget to fund additional promises in other areas just to keep the Lib-Lab pact on line. I would also like a breakdown of the funding; I will be lodging a written question to that effect.

Apart from the nine specific funding pledges, the action plan also includes the creation of two new national posts, at least one task force, six new strategies, one more advisory panel, another new expert group and various other new groups to co-ordinate activities. At least seven commitments in this white paper are to include the councils. However, I bring to the minister's attention the fact that neither the paper nor her speech mentioned including general practitioners. Social inclusion would seem to include councils, but the Scottish Conservative party would like assurances that GPs will remain at the forefront of health delivery in Scotland and be fully included in the new plans. The record of Scottish council social work departments in delivering care in the community and blocking beds in our hospitals is nothing short of a national scandal, and yet councils are given a priority and recognition beyond that of the tried and tested backbone of the health service-the GPs.

On the smoking ban in public places proposed by Hugh Henry, as a new Parliament we must ask why, in December 1988, Donald Dewar, as Secretary of State for Scotland in Westminster, signed up to a voluntary agreement with the industry in response to the white paper "Smoking Kills", yet now finds it necessary to support and legislate for a ban on smoking in public places.

Photo of Mary Scanlon Mary Scanlon Conservative

I would rather continue. I have only eight minutes. Hugh Henry will have his chance.

Photo of Hugh Henry Hugh Henry Labour

I would like to correct some of the inaccuracies in Mary Scanlon's statement.

Photo of Hugh Henry Hugh Henry Labour

I would like to see the evidence for Mary Scanlon's statement that I am calling for a ban on public smoking. I have made no such call, and I am unaware that there has been one. The proposals that I will introduce will not be on that basis. Can Mary Scanlon provide clarification?

Photo of Mary Scanlon Mary Scanlon Conservative

I think that Hugh Henry needs a better spin doctor. Having spent the summer in the Highlands, I read the newspapers like everyone else, which assumed that he was calling for a ban. He needs to employ another spin doctor.

We must consult and work together but, having consulted, we should implement practical measures to address the health of the people of Scotland and not continue building on ever-increasing and expensive bureaucracy and focus groups, only to leave the patients' most-used link with the health service out in the cold.

The health promotion arm of public health has huge status and a huge cost, but it is not generally recognised as cost-effective. For as long as I can remember, we have identified the problems in Scotland's health. For as long as I can remember, we have ploughed more money into health-even more than our English neighbours-yet we are not making significant inroads into the problems.

I will give the minister three examples of where we could move from bureaucracy and administration to front-line delivery, which I acknowledge that the minister mentioned. I will give three simple examples of what can be done. Part of the health promotion budget should be given to GPs to help them engage more fully in health promotion. Cardiovascular health could be monitored by GPs, as they know all their patients and could take blood pressure and work to treat this chronic disease early. GPs could also assist in a campaign to reduce smoking-that could be tackled along with hypertension.

As I visited various GPs and hospitals during the summer, the most serious concern that people raised with me was chlamydia. Chlamydia is given a passing mention in the document, yet 10 per cent of young, sexually active people are affected by it. It is a symptomless problem that causes infertility. It affects both males and females, yet there is no pilot project in Scotland to address the problem and most health boards have not budgeted for the machine that is used for early detection.

By strengthening the relationship with GPs, we could also address the problem of young men not attending doctors' surgeries. The suicide rate among young men is alarming and I have no doubt that we are all concerned about it. Only 10 per cent of screening for chlamydia is done on males. That could easily be addressed by bringing the GPs to the front line of health delivery. The treatment is a simple course of antibiotics, which can prevent infertility.

I use those three practical examples of how we could improve health care as a distinct option to the grand, centralised, bureaucratic and expensive approach outlined in the document. Where does the document focus on applying direct, immediate help for young single mothers who are smoking? Cigarettes are a cause of deprivation, as they affect the household budget, and smoking-related illnesses cost the NHS £1.8 billion a year. Where is the direct help to bring young males into GP surgeries and tackle the alarming suicide rate? I ask Susan Deacon not to get buried in paperwork and focus groups, but to work with the Health and Community Care Committee and health providers to promote good public health in Scotland.

I move, as an amendment to motion S1M-105, in the name of Susan Deacon, to leave out from "the key" to end and insert "that a partnership between individuals and health providers based on shared responsibilities is a better route to improving health in Scotland than the Executive's plans, based on 'improved life circumstances' and action in relation to 'health topics', which are failing the people of Scotland."

Photo of Kay Ullrich Kay Ullrich Scottish National Party 3:38 pm, 1st September 1999

I plan to spend my time addressing the issues raised by the minister, but I must express my utter dismay at the tone of the amendment offered by the Tories. I was particularly dismayed by Mary Scanlon's slur on Scottish social work departments and social workers who continue to do a splendid job in community care, despite years of funding cuts. I want that put on the record.

What can we expect from a party that decimated the health service during its 18 years of misrule; a party that gave us the internal market and GP fundholding?

Photo of Kay Ullrich Kay Ullrich Scottish National Party

No. What can we expect from a party that fought the Scottish election campaign on yet another major structural change in the health service in Scotland, which it was proposing to put into place a mere two months after the changes implemented on 1 April this year? The SNP-we have stated it-has reservations about the new structure, but we feel that it is more important for the morale of the workers in the health service, and especially for patients, to allow the new structure time to settle in. We will monitor it to ensure that it delivers a first-rate health service in Scotland.

We have just heard from a party that, had it won the Scottish election-I know that pigs might fly but, for the sake of argument, members should bear with me-would have scrapped primary care trusts and local health care co-operatives. Astonishingly, in the context of this debate, it would have abolished the health boards, which play a key role in public health service delivery. In spite of the Black report in 1980, throughout the long, long years of Tory rule, poverty was the condition that dared not speak its name.

Photo of David McLetchie David McLetchie Conservative

May I remind the member, in case she is suffering from forgetfulness, that she is part of the Opposition and that we are meant to be debating the Government's proposals on public health? We have no objection to defending our record in government, as Mr Gallie did robustly in his comments to the minister, and if Mrs Ullrich wants to rerun the election campaign we will happily do so privately.

Photo of Kay Ullrich Kay Ullrich Scottish National Party

Does Mr McLetchie want to cancel all his party's policies now?

Photo of David McLetchie David McLetchie Conservative

Will Mrs Ullrich get on with the job of being part of an effective Opposition in this Parliament?

Photo of Kay Ullrich Kay Ullrich Scottish National Party

By the tone of the previous speech, it is clear that the Conservatives are still giving out the same old, tired Tory line-"Don't worry, baby. Keep the faith." I will deal with the Government later.

Poverty was the condition that dared not speak its name and the white paper is to be commended for at last recognising the undoubted link between poverty and ill health. As Susan said, this nation of ours has the worst health record in Europe. It is no coincidence that one in three of Scotland's children lives below the poverty line, that more than 20,000 Scottish children are homeless in any given year, and that every year fuel poverty contributes to the deaths of 2,500 of our elderly people.

Those are cold figures when read on the printed page, but they represent real people suffering real hardship in Scotland today. I do not know about everybody in this Parliament, but I find it an absolute obscenity that Scotland, the most fuel-rich nation in Europe, should have the worst winter deaths record in Europe. Fuel poverty amid fuel plenty must not be tolerated by this Parliament.

The exciting thing is that this Parliament has a unique opportunity to tackle the scandal of poverty and ill health in Scotland. There can be no one in this chamber today who does not want to improve the health and quality of life of our fellow citizens. I, for one, believe that improving Scotland's health and eradicating poverty are the number one challenge that faces this Parliament. If we are to achieve that goal, we must take an integrated and-I hope-consensual approach to the issue.

The key is to recognise-as, I believe, the white paper goes some way towards doing-that poor public health cannot be tackled in isolation. There is hardly a legislative area that does not have an impact on poverty and ill health. That is why the SNP argues for a minister with responsibility for public health, so that we can truly raise public health to the top of the agenda. After all, community care has-rightly-been recognised by the appointment of a responsible minister.

The appointment of a minister for public health would underline our commitment to improving our nation's health. The minister would play a pivotal role in an anti-poverty strategy. He or she would be responsible for auditing-or, as I prefer to say, poverty-proofing-each piece of legislation at a pre-legislative stage, and for analysing the potential impact on poverty and public health of proposed legislation. It is essential that we, as a Parliament, develop an anti-poverty strategy for Scotland, with a dedicated key minister responsible for implementing it.

It is also imperative that the number of public health consultants in Scotland be returned to at least its previous level. In the past 10 years, we have lost almost 50 per cent of our public health consultants. The reason for that is quite simple-the continued inclusion of public health doctors in health board management costs. The truth is that those specialists have been lost not by design, but by cuts by stealth. It is easy for cash-strapped health boards to make cuts in an area that is not as visible as others.

If we are to restore the morale and the effectiveness of the public health profession, it is essential that the minister reassert the right of freedom of speech for public health consultants. They must be allowed to speak out in the public interest without fear of professional repercussions.

I commend the target setting in the white paper. Nobody can disagree with the sentiments that the minister expressed-at least, that is what I thought until Mary Scanlon made her speech. If we are to achieve those targets, new money will require to be invested in key target areas-of which I can suggest a few. We need to start public health training in the community and increase the number of skilled nurses who are available to work with people to improve public health at local level. Money must be invested to allow community nurses to gain further public health qualifications. New resources should be focused on public health initiatives in GP practices and in outreach work. I ask the minister to set a target to provide every GP practice with access to a named learning disability nurse by the end of this session.

Another example of the Government putting its money where its mouth is would be the target for dental health in children under the age of five. The best way to encourage families to ensure dental care for their children is for the parents to visit their dentist regularly. That could be achieved with an investment of only £4.5 million a year to reintroduce a free annual dental check-up for everybody in Scotland. That would help to make a visit to the dentist a family norm and encourage good dental health from an early age.

Photo of Phil Gallie Phil Gallie Conservative

The minister mentioned fluoridation of the water supply in her speech. The British Dental Association, which recognises the problem of dental health in the under-fives, suggests that the best way forward would be fluoridation. Does Kay Ullrich accept that the British Dental Association might be right?

Photo of Kay Ullrich Kay Ullrich Scottish National Party

Yes; that is why I am sure fluoridation of water will be a high priority for the Health and Community Care Committee. The issue must be debated and we would be happy to do so.

The biggest barrier to good health is low income. With more than £380 million of benefit lying unclaimed every year, it is essential that we invest in a nationwide benefit take-up initiative. Members should think of the difference that would make to the 40 per cent of Scottish pensioners who are not claiming the benefits to which they are entitled.

I welcome the measures that the minister announced today-as far as they go. I am sure that everyone in this chamber wants to reverse Scotland's abysmal health record and the appalling obscenity of poverty. In spite of the Tory amendment, I urge everyone to put behind us the yah-boo politics so beloved of Westminster. The health of the people of Scotland demands that we work together to examine the legislation in terms of public health and poverty and set ourselves the task-before this session ends-of removing from Scotland the title of the sickest nation in Europe.

A nation is judged by how it cares for its most vulnerable citizens. Let the members of this Parliament be determined that we will not be found wanting when that judgment is made.

Photo of Patricia Ferguson Patricia Ferguson Labour

I remind members that the time allocated for speeches in this part of the debate is four minutes. Members should try to adhere to that as far as possible.

Photo of Margaret Smith Margaret Smith Liberal Democrat 3:50 pm, 1st September 1999

I am glad that we have come to the issue of public health so soon after our long holidays. I am sure that we have all come back more stressed out than we were when the recess began.

Public health is the No 1 issue that the Health and Community Care Committee must address and the Parliament must tackle. It is the major issue facing Scotland and we should have it at the top of our political agenda, no matter which party we represent. From time to time, as the Convener of the Health and Community Care Committee, I have in a way to try to be representative of no political party. By so doing, I hope that I can pull together the talents of the exceptional people on that committee to take forward the public health agenda as a matter of urgency.

All of us should be able to wheel in behind the broad themes of the white paper and embrace the three-pronged approach to addressing inequalities in health against the background of the inequalities of life. We must improve the life circumstances of all our fellow citizens. It is obvious that that will have a spin-off impact on public health and individual health.

Photo of Kenneth Gibson Kenneth Gibson Scottish National Party

Although the white paper is a first-rate document, does the member agree that the fact that there appears to be no mention of the Executive's plans to reduce the incidence of suicide, which is at a record level in Scotland, is a serious omission?

Photo of Margaret Smith Margaret Smith Liberal Democrat

I agree. We have all received representations about the level of suicide, particularly among young men. It is an issue of some concern that has already been raised by Mrs Scanlon. I hope that whoever is sweeping up for the Executive will address that point. We will listen with keen interest.

We can all agree on the broad themes of the white paper and the three-pronged approach to address health inequalities and life circumstances. There is an obvious need to tackle lifestyles; that is where I agree wholeheartedly with Mary Scanlon. In all of this, there is a role for government, health professionals, general practitioners, nurses, community nurses, pharmacists and a range of other people. Indeed, as we will see in the debate, there is a role for other professionals, in social work and in education.

At the heart of this, however, there is a role for the individual. Nobody makes people do the things that cause them ill health. Sometimes they have no way out of it, but sometimes they do. The cancer screening issue that Mary brought up highlighted that fact. Every one of us has to take responsibility-as women or as individuals-for our own health and that of our children.

The prevention of heart disease, cancer and accidents is an agenda that we should all be able to take forward from this point and claim ownership of as the agenda for the Parliament. Everyone agrees that unemployment and poverty have a devastating impact on health. Everyone knows that to change lifestyles, we must target our children and young people in relation to diet, smoking, alcohol, exercise and sexual activity.

Everyone knows that as well as warm words from our politicians, the health professionals, people and patients of Scotland need resources and a co-ordinated approach based on solid evidence and practical experience through demonstration projects. That is why the demonstration projects are one of the key elements of the white paper. They are the kind of thing that health boards and others across Scotland will take forward in partnership time and time again. That is why I welcome the motion, the contents of the partnership agreement and the broad principles-if not every dot and comma-of the white paper.

Despite the amendment, there remains a high level of consensus on the actions needed on public health. We should make no mistake-this is a crucial issue. As Mrs Ullrich said, it is not just one issue; there are many issues on which we will have to take hard decisions and on which there will be tough, opinionated debating.

Before the election, I asked my dentist what measures he would bring in if he were elected to the Scottish Parliament. He replied that there were two. The first was water fluoridation. I think we were right to say that the Health and Community Care Committee ought to consider that as a matter of urgency. His second measure was a ban on chocolate. As I was trying to be elected and to get some of the female vote in Edinburgh West, I declined to take that on as a campaigning issue, but he is right: sugar in sweets and sugary drinks are rotting our children's teeth. That is why we must consider fluoridation of water in the Parliament and in the committee.

Photo of Patricia Ferguson Patricia Ferguson Labour

Please come to a close, Mrs Smith.

Photo of Margaret Smith Margaret Smith Liberal Democrat

There are a number of other issues, such as smoking, which kills 13,000 Scots every year. They are not statistics; they are mums and dads, sons and daughters. We must examine those issues. Addiction, dental health, smoking, food safety and fluoridation will be filling our agenda in the coming months. I look forward to working with people of all parties, with the minister and with people in health and community care throughout Scotland to ensure that we deliver a healthier Scotland and a sustainable and excellent public health care agenda.

Photo of Malcolm Chisholm Malcolm Chisholm Labour 3:56 pm, 1st September 1999

If anybody outside-or indeed inside-the Parliament does not have time to read "Towards a Healthier Scotland", I suggest they look at the jigsaw on the front. That symbol embodies the new holistic approach to health, which sees that life circumstances issues such as housing, income, employment and the environment are just as relevant to health as traditional lifestyle issues such as diet and smoking, which are, of course, often related to the life circumstances issues.

If people have time to read only one word of the document, I suggest that they highlight the word inequalities, because that is the main theme of the document and it must be our main objective in health policy; we must address the scandalous inequalities of health in Scottish society, which are related to income.

I hope that when we do health impact assessments on all policy we will address in particular the effects of all policies on health inequalities. I also hope that, as this Parliament goes on, we will work out targets for reducing health inequalities, because there could be no more fitting monument to the first session of this Parliament than the achievement of a significant reduction in health inequalities in Scotland.

I welcome Kay Ullrich's speech and the consensual approach that she adopted, but I very much disagree with Phil Gallie and Mary Scanlon. Health inequalities widened considerably under the previous Government; we can have debates-as Phil Gallie wanted-about the level of health expenditure, but that widening is the simple reality. The standard mortality ratio for someone in the poorest community in 1981 was 120 per cent of that of someone in the most affluent communities; by 1991 that had grown to 162 per cent.

Mortality is not the only indicator. Only last week, I read a report about mental health in Glasgow that showed clearly that there were far more mental health issues in deprived areas, showing that mental health, too, is related to poverty and life circumstances.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I have only two minutes left. I am sorry I cannot give way, but I look forward to discussing the issue in the Health and Community Care Committee and elsewhere.

I welcome the minister's emphasis on minus one to five-the years of life, including the period in the womb, when all the evidence shows that issues such as birth weight are so significant. It is really good that the Executive is emphasising that. That too is related, as the Acheson report in England reminded us, to levels of income. In terms of welfare reform, we have to consider the income of pregnant women as well as women in the early years of their children's lives.

Food is a good example of how income issues relate to the lifestyle issue of diet. I would like to expand on that, but time does not allow me to do so. I will just say that in my constituency there is an excellent food project called Barry Grub, which tries to provide healthy food at wholesale rates in the Pilton area. We should consider food co-operatives and initiatives so that the problems poor families have buying healthy food are addressed.

The emphasis on mental health in the white paper is also very important. If I may advertise my constituency again, I will mention that there is an excellent community mental health project in my constituency, called The Stress Centre. The Executive should support initiatives such as that, which address the higher levels of mental health problems in certain areas.

There are many initiatives on mental health. I was glad to see circulars from the Executive on post-natal depression and on domestic violence, as both are closely related to mental health. I hope that the Healthy Respect project on teenage pregnancy will also consider how men and women relate to each other-they should certainly not do so with violence and inequality.

Time is almost up, but I have one final important point about the white paper. The issue is not just about addressing life circumstances and lifestyle; it is also about involving people at the grass roots in decisions about their health care. I am pleased that the proposals for the task force make that point. The task force will involve people from local communities, and that bottom-up approach is fundamental. It is practised in many community health projects, such as the one in my constituency.

I hope that, if there is any money floating around after the review, some small sums could be targeted towards community health projects as part of the social inclusion partnerships. Those projects involve local people in addressing those issues, which are a challenge to us all.

Photo of Tricia Marwick Tricia Marwick Scottish National Party 4:01 pm, 1st September 1999

I associate myself with the comments made by my colleague, Kay Ullrich. There is much in the white paper that commends itself to all members. I want to address a number of issues.

For some of us, the lifestyle that we choose has a bearing on the life that we eventually have. I want to concentrate on those who have no lifestyle choices and no choice about the life that they live.

"Action on life circumstances is the rock on which work to improve lifestyles and tackle disease will stand or fall."

Those are fine words from "Towards a Healthier Scotland"-and the minister talked about tackling the root causes of ill health-but there is one startling omission from the action points in that document. Its authors have not said how they intend to tackle damp housing in Scotland.

Thirty per cent of children in Scotland live in damp houses. More than half a million children and pensioners have no choice about the circumstances in which they live. The link between damp housing and health is well established. Asthma, bronchitis and other respiratory diseases are prevalent among people who live in houses that are riddled with damp.

A study of damp housing and asthma in Glasgow, published in 1996, states:

"The greater the severity of dampness or mould in the home the more likely the patient was to have severe asthma."

More children suffer from asthma in Scotland than anywhere else in Europe.

All of us come into this chamber with experience from previous jobs and from events in our lives. I am no exception. While I worked for Shelter, I came into contact with people in the most appalling housing conditions. I met mothers who were in despair because their babies were constantly being admitted to hospital with respiratory diseases, and children who could not go to school because their clothes stank of dampness.

One such mother was Michelle from Glasgow, whose young son had been constantly in hospital; he screamed non-stop and he failed to thrive. Consultants finally discovered that he was suffering from Weil's disease, a rare illness caused by being exposed to rat urine. The rats were living under the floorboards in a Glasgow City Council house, scraping and scratching all night and terrifying the family. The disease has left that child with no lining in his nasal passages and his health will be affected for the rest of his life.

What choice did that baby have in the lifestyle or life circumstances in which he was being brought up? I warn members that I shall return again and again to the issue of dampness and health. I ask the minister why, having mentioned damp housing in the document, she is not setting targets for tackling dampness in Scottish homes. Why have no targets been set for reducing respiratory diseases?

In the earlier part of this century, the massive investment in public housing came as a drive to improve public health. The departments have forgotten the lesson of the joined-up thinking of 60 years ago. We must re-establish the link between housing and public health.

It does not have to be like this. We need to invest money to tackle dampness. A recent project in Cornwall invested £300,000 in housing to improve the homes of children with asthma. Central heating was installed, dampness was eliminated, the children's health and school attendance improved and their life chances improved as a result.

I welcome the white paper, but it does not go far enough. We will never improve the health of our nation until we improve the state of the homes in which people live.

Photo of Ben Wallace Ben Wallace Conservative 4:05 pm, 1st September 1999

I would like to make it clear from the outset that I am in favour of public health. [Laughter.] As Margaret Smith will testify, I am always on at her to get sport and prevention into committee work, so that we can introduce measures which we hope will pay off in the future by alleviating the demands on the health service.

I reiterate the point made by my colleague Mary Scanlon: individual responsibility is something that we must develop. If we do not, we will have to produce another white paper on public health in five, 10 or 20 years' time.

I visited Tayside Health Board to get a briefing on the cervical smear tragedy, when 19,000 women fell through the screening net. There are many problems that the board will investigate and on which it will report. However, as Mary mentioned, a number of the women were sent repeated reminders and requests.

In Braemar, where I lived last year, every weekend, brave men and women of the mountain rescue service would rescue injured people off the mountain and send them to hospital by helicopter. Many of the people they rescue go climbing unprepared and ignore advice.

In all those cases, the NHS has to foot the bill. It worries me that a public health culture is emerging that expects the state to follow people around, tidying up after them. People who make such errors rob the health service of much needed funds-funds that could be better used to care for leukaemia sufferers or the elderly.

My difficulty with "Towards a Healthier Scotland" is not its aims, but the way in which they will be implemented. Public health should be a contract between the health service and society-it must work both ways. The white paper sets out three processes for achieving better public health. It blames much on life circumstances. I agree with the observation that crime, low pay and conditions and poor education contribute to ill health. I also support the housing measures and the fact that the white paper recognises that poor housing contributes to poor health. However, it also relies on the fact that the new deal is working, that new Labour is improving education, and that jobs and prosperity are increasing.

Nevertheless, in the past two and a half years we have seen an increase in violent and drug-based crime. This year, we have seen the pupil-teacher ratio rise. We have seen rural economies in the Borders and in the Highlands in recession. The Executive's measures are not helping the farmer and the manufacturer to feel better about their circumstances.

What sort of message is the Executive sending about public health to the people of Scotland when the young doctors at the very heart of the NHS are exempted from the pay and conditions that they deserve?

One of the best ways to create better life circumstances is to create better jobs. However, there are more and more regulations on small businesses, which need to be encouraged in the deprived parts of Scotland. Nearly 2,000 extra regulations have been imposed on business since Labour came to power. I would like to deregulate to allow communities to thrive again.

Susan Deacon said that she would take no lectures from us after our 18 years of government. However, I will not take lectures from a party that put Bernie Ecclestone's £1 million bung before the interests of public health. Labour cannot wriggle out of that, because its proposals for tobacco advertising bans for everyone except Bernie Ecclestone are there for all to see.

I was disappointed that the minister never once mentioned drugs. I understand that there will be separate proposals, but drugs are such a part of society now that drugs policy must be intertwined with the public health strategy from the very bottom. No doubt the thousands of people who are alleged to take ecstasy illegally every weekend will be the first to expect the national health service to treat them for their problems in 20 years' time.

The final jigsaw piece for a healthier Scotland is action on health topics. I welcome the cautious moves towards fluoridation and the stepping up of the initiatives of the Health Education Board for Scotland to educate people about the dangers of heart disease. However, statistics that came out a few weeks ago show that cases of cancer, cases of sexually transmitted diseases, waiting lists and teenage pregnancies have all risen, this year and last year. Some of the statistics have bucked the trend from the time when we were in government. It is hard to see how getting a healthier Scotland can be achieved under Labour without developing more measures to take people's individual responsibility into account. I urge the Parliament to back our amendment.

Photo of Des McNulty Des McNulty Labour 4:11 pm, 1st September 1999

Some sad and misguided people apart, there is, I believe, a widespread consensus in the health service and among the people of Scotland in support of the objectives set out in the public health white paper-especially in the action points in the white paper's summary. I was a member of the working group set up by Sam Galbraith while he was the Scottish health minister, which decided the health targets for incorporation in the white paper. I can testify to the rigour with which those targets were set. It was intended that they should pose a challenge-not just for the health service, but for other public agencies. Local authorities will have a vital part to play, as will the voluntary sector and the Scottish Parliament.

The fact that the Government now firmly recognises that poor health has its roots in poverty, inadequate housing and joblessness-as well as in associated lifestyle factors such as poor diet and lack of exercise-represents a tremendous break with the past. The previous Conservative Government's denial of those causal connections-in the face of overwhelming expert advice-undoubtedly held back progress between 1979 and 1997. We have already heard from Mary Scanlon, whose advice was essentially to do nothing. She criticised a series of actions to be taken, but she had nothing to put in their place-apart from muttered comments about individual responsibility. Yes, individual responsibility exists, but so does society's responsibility. If we are to tackle Scotland's health problems, society has to take responsibility. The prime place for that responsibility to be exercised is in this Parliament.

Photo of Des McNulty Des McNulty Labour

No, I will not. I believe that we have strong-overwhelming-scientific evidence of the causes of ill health and of the steps that we need to take to improve the situation. What is required from the health minister-and equally from those of her ministerial colleagues whose responsibilities bear on health, which is virtually all of them-is a consistency and firmness of purpose in making the improvement of Scotland's health a key priority. All too often in the past, public health and health promotion departments have been a cinderella within the health service, knocked aside or downgraded when the pressures on acute hospital services accumulated. What is needed is a continuing commitment-through local government, housing and employment policies, as well as through the health budget and the health service-to make tackling health inequalities one of the Government's key objectives. The message that I am getting from the minister is that that appeal has been heard.

The minister's speech, together with the white paper, makes it clear that the campaign against poor health will be closely tied to broader efforts to deal with social exclusion, concentrating people's efforts across the sectors by working to a shared agenda. On the ground, I detect a strong sense of common purpose among all those working in health and in related fields to tackle those inequalities. That is what they want to do, and that is what we in this Parliament have to empower and encourage them to do.

Health has been given a high priority-not only because of its importance in terms of people's social well-being, but because the measurement of progress towards meeting health targets provides us with an objective and robust method of assessing progress towards social inclusion and equality. To meet the targets set out in the white paper, we will need to advance partnership working and the co-ordination of the work of different agencies in a way that builds on existing good practice but breaks new ground.

Despite the deep-seated health inequalities in Scotland and the unacceptably high rates of coronary heart disease, cancer and strokes in particular, it is my experience that a lot of hard work is already being done to tackle our health problems. As the former chair of the Glasgow Healthy City Partnership, I know that a great deal has already been done on the ground to tap into the creativity of people living in some of the more deprived communities, as well as the expertise of health practitioners. Concrete efforts have been made to build paths away from health disadvantage.

Community health projects and projects that focus on specific needs-and I must say that I could provide an even longer list than Malcolm-have had a major impact. They work in developing greater health awareness and providing much needed support to people for improving their health. The centre for women's health in Glasgow is an example of an internationally recognised centre of excellence. There is a great deal of existing good practice in Scotland-we are not working from the back of the field. People are coming to Scotland from elsewhere in the UK and from Europe to look at what we are doing and to learn lessons that they can apply to their circumstances. There is much that can be put into effect very quickly given the commitment that is now being shown.

Photo of Des McNulty Des McNulty Labour

I ask the minister not only to work through official channels-the department that she oversees, health boards and trusts-but to spread the agenda more widely. People must be encouraged to be more directly involved in improving their health. The statement that the minister made today, which mentioned £15 million for demonstration projects, the encouragement that has been given to people through the new opportunities fund and the bringing forward of proposals for healthy living centres are all positive steps. Let us, however, be clear that we are not engaged in a short-term sprint. This is a long haul and what we need is the consistency, firmness and determination to succeed over the next 15 years. I hope that we can go forward together in this Parliament to play our part.

Photo of Shona Robison Shona Robison Scottish National Party 4:16 pm, 1st September 1999

There is nothing in what Susan Deacon said that any reasonable person could disagree with. Everyone wants to improve public health in Scotland. In "Towards a Healthier Scotland" we read about improving life circumstances and tackling inequalities in health. Stress is laid on working in partnership and the development of plans and projects is a key part of the health strategy.

That is all good stuff, but at that point I begin to have a bit of a problem. Susan Deacon was keen to tell us the good news, but did not mention the other side, which is not such good news. She talked about partnership and about working closely with the Health Education Board for Scotland, but HEBS funding has been cut by £400,000. I fail to see how that would improve partnership working.

In addition, Government support for local council spending is £1.3 billion less in the first three years of the Labour Government than it was in the last three years under the Tories. That has meant a slashing of local authority budgets. It means that many of the socially excluded communities that ministers are so fond of referring to and of visiting have experienced savage cuts in many of the services and projects that are important in tackling public health problems.

Public health problems can be tackled best at community level using the services and projects there, but the cuts have resulted in a loss of services to the neediest people in society. I will give some examples.

The Whitfield Health and Information Project in Dundee closed last year when its funding ended. That project provided advice on sex education, teenage pregnancies and diet and nutrition, among other things-the very areas where we want improvement. The Glasgow North Community Health Project has suffered a cut of £15,000 to its budget. That has reduced its ability to carry out much needed work in one of Scotland's most deprived areas.

It does not stop there. The threat to projects continues to this day. The funding of the Incite drugs project in Aberdeen ended in July. Only through public appeal has that project managed to continue. With only one of the three funding partners having agreed to future funding, the project is under serious threat, yet it is involved in important drug abuse prevention work and peer education with young people. It is the very type of project that we want to tackle public health problems.

This is not intended to be partisan. In a previous life, many members from other parties have been involved in working on such projects in very deprived communities. They know as well as I do that there has been cut after cut to the examples of good practice that Des McNulty mentioned. The minister has to take on board the fact that we must secure those projects.

I want to mention several other points that the minister might want to pick up on. Will she make a statement about the important issue of the shortage of vaccines, which is a matter of concern for many doctors? I implore her to examine discrimination in health service delivery. Several organisations have raised, through the Equal Opportunities Committee, the issue of the lack of interpreting and translating services. For someone whose first language is not English, it is difficult to communicate important health information that will help towards a diagnosis, or to understand a diagnosis when it is given; and it is stressful for both people and doctors when patients do not fully understand the information that they are given. The problem needs to be addressed and I hope that the minister will investigate the matter.

Photo of Robert Brown Robert Brown Liberal Democrat 4:21 pm, 1st September 1999

The two things that we should take away from this excellent debate were encapsulated in Des McNulty's remarks about the need for building on examples of good practice and for thinking long term. This is a subject where it is easy to talk about quick fixes or about what will be necessary for the next 12 months.

The white paper, as refocused by the partnership agreement, concentrates on the underlying causes of ill health and on the importance of health promotion and of locally based health initiatives. I welcome the minister's approach in involving the whole chamber, the whole Parliament and the whole of Scotland in tackling health. That approach has been welcomed by the whole chamber, with the possible exception of the remnants of the ideologically driven Conservative group on our far right.

The Liberal Democrats are keen to pursue the aspects of the partnership programme that link health to housing. If the warm deal and healthy homes initiatives could help to rid Scotland of the scourge of damp, cold houses which some members have mentioned, that would be a major achievement for the Executive and the Parliament and a major contribution to good health. It is entirely uninspiring that, on the eve of the 21st century, far more people in Scotland live in such accommodation with its associated health and morale problems.

Photo of Tricia Marwick Tricia Marwick Scottish National Party

Will Mr Brown join me in condemning the Executive for cutting £176 million from Scottish housing? Does he agree that the Executive-or the Labour party-is spending less on Scottish housing in its first three years than the Tory Government spent in its last three years?

Photo of Robert Brown Robert Brown Liberal Democrat

On funding, the initiatives have to be taken as a whole. [Interruption.] Seriously- let us wait and see what the partnership Government has achieved by the end of the period. As the coalition parties have been in power only since 1 July, it is a little premature to talk about investment figures over that three-year period.

Returning to my main point that the emphasis on social factors should not lead us to overlook the need to target specific health promotion issues, I think that it was correct for the partnership agreement to insist on such an approach rather than on the chimera of hospital waiting lists. There will always be political pressures to deal with the high-tech end of hospitals, because that attracts all the publicity, but the priority should be placed on the slow, steady work of the health service.

In connection with that point, I was a little concerned to read in the white paper of difficulties at the edge between local government and health. It might not be that important to have health officials sit on local government committees, but it is vital that the link between the two services be as seamless as possible so that the policy is not hide-bound by such matters as departmental difficulties. We have to give much attention to drawing the strands together in different ways.

My final point relates to cancer. We have failed young women abysmally in the campaign to reduce tobacco usage. Why? It seems slightly perverse because women are far better than men are at going to the doctor. They go to the doctor about childbirth and associated pre and post-natal care and are in contact with community organisations of all sorts such as mother-and-toddler groups, weightwatchers groups and yoga classes. It is possible to target young women more effectively. The link between the health of young women and the unfortunate upward trend in cigarette smoking, and similar links, can hardly be overemphasised.

A while back I was involved in litigation in England-members might have read about it-on coal miners and their associated problems. An extraordinary and significant fact that emerged was that a moderate cigarette smoker suffers more damage to his lungs than he does from 20 years down the mines with their dampness and dust.

The Conservative amendment fails significantly to recognise the role of the Government. The role of the Government in public health is threefold: to resource public health, to co-ordinate policies and to set ambitious but achievable targets to tackle the problems that we have been talking about. The minister's speech and white paper hit the issue on the head. Let us consider the details unitedly and try to deliver those improvements in health.

Photo of Robin Harper Robin Harper Green 4:26 pm, 1st September 1999

I would like to address the remarks made earlier by Phil Gallie and Tricia Marwick, although I see that she has disappeared.

The Black report, commissioned in 1977 and produced in 1980, was the first significant report to link poverty with ill health. The subsequent Conservative Administration shelved the report and was partly responsible for the increase in the amount that had to be spent on health over that period because the problems created by the link between poor housing and ill health were not being addressed, which were clearly set out in the Black report. I support Tricia Marwick every time she calls for better insulation standards for Scottish homes and for a rolling programme of insulation improvements, particularly to public housing. If we could raise the basic building standards for housing in Scotland, we would go a long way towards solving many of our problems.

Photo of Robin Harper Robin Harper Green

There are two additional points. First, the UK made commitments at Kyoto to reduce CO 2. If we reduce the amount of fuel that is used in housing, which makes a considerable contribution to CO 2, that will help us to meet our CO 2 commitments made at Kyoto and we will also reduce pollution generally.

Photo of Robin Harper Robin Harper Green

No, I want to continue.

Secondly, Margaret Smith commented that her dentist had said that two issues were the reduction of the amount of chocolate eaten and the introduction of fluoridation. There is a danger of getting them in the wrong order. Why do we not first address the real causes of dental decay? To address the causes of tooth decay, we need to put in place essential education, changes in culture and in eating habits and anything else that we can think of. In the fluoridation debate, there are plenty of informed and reasonable arguments in favour of introducing fluoridation and equally well-informed and progressive arguments against fluoridation. I will stand against fluoridation and I hope that the argument will be revealing, intense and sensible.

Generally speaking, the white paper is good and I wish the Executive the best of luck with it, but there are aspects that could be improved.

Photo of George Reid George Reid Scottish National Party

Mr Alex Fergusson will speak next and I ask him to keep it brief.

Photo of Alex Fergusson Alex Fergusson Conservative 4:30 pm, 1st September 1999

It is with a certain amount of trepidation that I enter this debate, because I acknowledge that my subject rolls into the fields of justice, education and social services, as well as taking its primary place within the health service. I strongly believe that my subject is not only one of the greatest dangers to our health, as a nation, but is capable of damaging the social structure of our society. It is a curse that knows no boundaries of class, creed, wealth, colour or political affiliation and that frightens all parents as their children grow up in today's society. It is a curse that has an adverse affect on every community, no matter how large or small, and that we must address, as a Parliament whose aim-indeed whose promise-is to improve the lot of those in our society who can least help themselves. I refer, of course, to drugs and to those who use, misuse and abuse them. Any debate about those who supply them is for another occasion.

As a Parliament, we will be guilty of the utmost neglect if we are not able to concentrate on and prioritise the issue of drugs in our first four-year term of office. The rewards of making progress would be enormous; for example, there would be huge benefits in terms of police resources. Just this week, I had a meeting with the chief constable of Dumfries and Galloway, who informed me that 70 per cent of crime in that region was directly drugs related.

There would be equally enormous benefits to our social services and to our local authority resources, but the greatest benefit would be to our health service and consequently to the health status of our nation and its people. It is surely incumbent on this Parliament to try to achieve those benefits because, as the minister said, we have a magnificent opportunity to take a new initiative on this and other issues.

I have spoken to many people who are involved in drugs rehabilitation and I keep coming up against the view-interesting and unusual these days-that there is plenty of money being thrown at the problem. The Scottish Drugs Forum all-party working group's report states that £50 million annually is the current expenditure on response to drugs use. However, I am constantly told that that £50 million is not being used in the most effective way. We need to find the most effective ways, or best practice as it is better known, and we need to consider prevention through education. There is an overwhelming need for a national strategy rather than the fragmented one that is currently employed. Where we fail to prevent or to educate, we need to listen to those who work in rehabilitation and to listen and learn from those who have first-hand experience of the pain and peril of drug addiction.

Given the belief that sufficient resources are available, but that they could be better applied, the answer to some of the problems lies in another of the Executive's buzz words, which also appears in Mary Scanlon's amendment: partnership. This issue, above all, is surely the perfect one in which partnerships should be employed-between Government departments, local authority departments, the voluntary sector and individuals. The Government's drugs expert, Professor Howard Parker, predicts that we are on the verge of a new heroin epidemic, as if the present one was not serious enough. The announcement of a new drug enforcement agency, while welcome, brings problems of its own, not least in how that agency will be staffed without diluting the expertise on the ground. The agency will not in itself provide the whole answer.

The credibility of the Executive, indeed of the Parliament, is on trial to an extent, not least in the media. An urgent, innovative and joined-up approach to the drugs menace in our society would give us a golden opportunity for redemption. It will be to our eternal shame if we do not grasp that opportunity. I support the amendment.

Photo of Richard Simpson Richard Simpson Labour 4:34 pm, 1st September 1999

The establishment of a Scottish Parliament with broad and accountable responsibilities for health service provision in Scotland offers us a unique opportunity. The white paper demonstrates that the Government's approach is to consider the multi-factorial nature of Scotland's ill health and the fact that we require multi-agency solutions. Many of us who have practised medicine over the past 20 or 30 years have been engaged in the process of trying to promote health in Scotland, of almost preaching to people about health, and we have not made any substantial changes at all.

The Government has begun to promote health in an effective way by publishing a number of papers. Sir David Carter drew attention to these important initiatives in his report, which was published last month. The white paper, "Tackling Drugs in Scotland: Action in Partnership", to which Alex Fergusson alluded, is very important in terms of what we are going to do in the drugs field. A further initiative is "Smoking Kills", which was published in December 1998.

Sir David repeatedly drew attention to inequalities as the first challenge that has to be faced in every aspect of this area of work. The Government has placed inequality and children at the centre of the renewal strategy. At a national level, the long-term aim of eliminating child poverty has been established as a goal. The increase in child benefits, the establishment of the working families tax credit, the £100 allowance to the elderly to deal with dreadful death rates in winter and the warm deal initiative are important issues. In my constituency, the care and repair efforts that are being made through voluntary groups in partnership with local authorities will begin to deal with some of the housing problems that we are faced with.

I want to tell members briefly about the initiatives that the Government has taken in the heart of my constituency in Clackmannanshire, which is an area of some deprivation. For example, £2.7 million was made available for a social inclusion partnership and will support some of the efforts in the drugs field to which Mr Fergusson referred. The establishment of community schools, and the widening of that initiative, is very important in terms of health. The promotion of a healthy alliance, and the opportunity to establish a healthy living centre-for which we have submitted a bid-will help as well. Henry McLeish's visit to the constituency yesterday concentrated on the central problem of unemployment. Unless we tackle unemployment, we will not give people the self-esteem that is vital to good health. These initiatives contribute to a comprehensive strategy to renew my constituency and to deal with Scottish health problems.

Phil Gallie seemed to be feeling under some attack when he spoke earlier. I say to him, yes, the Conservatives did spend a lot more money on health, but what was that money spent on? The number of administrators was increased from 1,000 to over 12,000 under the Conservative Government, so the money was spent on administration, not on the appropriate issues that we need to address. We have already tried to start rolling that process back.

Turning to a point made by Robert Brown, there is one area into which I believe that we need to go further than-from what the white paper says-the Executive is prepared to go and on which we must provide clear leadership for the rest of the United Kingdom. The white paper contains a strategy on tobacco, and that strategy is also spelled out in "Smoking Kills". However, I do not believe that that strategy deals adequately with the problem of passive smoking. Sir David Carter's report states that, in North Lanarkshire, 43 per cent of people interviewed within a week of a survey being done mentioned passive smoking. Such figures are unacceptable, and we cannot tolerate passive smoking.

Tricia Marwick referred to asthma, which 5 per cent of adults and 10 per cent, or more, of children suffer from. Those figures are increasing, as has been demonstrated in studies in Grampian. Tobacco smoke is one of the most powerful triggers for acute asthma. There are 2,000 deaths from asthma annually. The Royal College of Physicians reported that 50 children a day are admitted to hospitals in the United Kingdom because of asthma triggered by cigarette smoke specifically.

Photo of Brian Monteith Brian Monteith Conservative

Is it not the case that, over the years, smoking has generally declined, while the number of cars and motor vehicles has increased? Does Dr Simpson accept that that increase outweighs passive smoking by far as a contributing factor to the growth of asthma?

Photo of Richard Simpson Richard Simpson Labour

This will be the briefest answer-no.

Smoking is undoubtedly the most proven health problem. If Hugh Henry's private member's bill does not get through, I will propose to the Health and Community Care Committee that it should use its powers to introduce legislation-and the committees in this Parliament have powers to do that, unlike Westminster-to bring about a ban on smoking in public places. That would set the tone for this Parliament, and would show that we are prepared to lead from the front, as well as being supported by the white paper's partnership from below. I recommend that approach to members.

Photo of Kenneth Gibson Kenneth Gibson Scottish National Party

On a point of order, Mr Deputy Speaker. Do you agree that, before he pontificates on the issue of tobacco, Mr Monteith should disclose that he is closely associated with the Freedom Organisation for the Right to Enjoy Smoking Tobacco?

Photo of George Reid George Reid Scottish National Party

I think that that is a matter for the individual member.

I call Mr David Davidson to wind up for the Scottish Conservatives.

Photo of David Davidson David Davidson Conservative 4:40 pm, 1st September 1999

Despite the comments from other parts of the chamber, we welcome today's debate. Whether we like it or not, health is one of the most important issues in Scotland. It is not one that we can easily deflect, or over which we should try to score brownie points from the past.

The Executive has produced documents for us to address, and the purpose of today is for us to give those documents due scrutiny. Some members have certainly risen to that. It is unfortunate that the minister got a little excited when she responded to Mr Gallie's intervention, but I am assured that if she talks to Mr Chisholm, he may be able to give her the address of the stress clinic in Pilton to which he referred earlier. Possibly we could all have a go at it when the time arises.

I have spent my life in the front line of medicine, in the form of community pharmacy. Most of that has been in areas that would be considered today as socially deprived, with poor housing and, more important, poor health, knowledge and education. When my colleagues and I talk about personal responsibility for our health, that is not an indictment of the individual who perhaps has not got the message. I think that personal responsibility for health can be explained very simply. It is for those of us in this chamber to ensure that every single person in the street understands-in the language that they use every day-exactly what they can do to help themselves and, more important, to help others help themselves.

Richard Simpson, a GP, must be very frustrated by the fact that people have called in to his surgery, have been given information and Health Education Board for Scotland leaflets and have gone off without getting the message. That is the underlying point. No amount of bureaucracy or additional task forces will easily address that question. We have a huge wealth of information on health care and on health issues-they are analysed to death in paper after paper. What we need is a proper campaign from the Executive to get across the message of personal health care to every individual. I agree with those who said earlier that that begins in the ante-natal clinic.

Photo of Karen Gillon Karen Gillon Labour

Does Mr Davidson agree that there are unequivocal links between health, poverty, housing and transport? The issues that he has identified in relation to personal choice are often not ones of choice for individuals. Poverty is often the most important factor affecting a person's health. Does his party acknowledge the link between poverty and ill health?

Photo of David Davidson David Davidson Conservative

Certainly. I would not deny that in the slightest, but I would make the point that it is only one of the factors. I do not dispute that some people are in poor housing, or that some pensioners suffer because they happen to own their houses, do not qualify for some benefits and therefore cannot afford to heat their houses. We must be a bit more circumspect about cherry-picking health issues.

We are talking about a major opportunity for this Parliament, and I welcome the fact that the minister has come here so early in the parliamentary year. However, there is point enough in looking at today's motion and at the amendment. The minister's proposal was about partnership, but does the man in the street not have the right to assume that it is the Government's job to act in partnership and to co-ordinate, regardless of the topic, on behalf of the people of Scotland? Mary Scanlon's amendment was about linking in and trying to assist the individual.

Please can we move on. Conservatives care as much as anybody else about the health of the people in Scotland. There are limited resources in the health service and it can no longer afford to pick up the tab for something that should have been cut off earlier on. If the Government is going to invest in early years intervention, we are with them. That will not only release resources for the future, but will reduce personal discomfort and pain in later life. I second Mary Scanlon's amendment.

Photo of Duncan Hamilton Duncan Hamilton Scottish National Party 4:45 pm, 1st September 1999

We have just heard the speech which described what the Tories wished they had said in their amendment. Mary Scanlon's amendment does not do what Mr Davidson was talking about at all. If we read it properly, it says that the Government's role is so diminished-and of course everyone understands that the individual has a responsibility and that much of the change that will happen will result from individuals changing their attitude and action-and tries to ensure that Government's role in the process is removed. Frankly, that is no good, because the whole point of what we are trying to achieve today is to make a cohesive move forward.

Mr Chisholm said that if we cannot read the white paper, we should just look at the cover, with the picture of a jigsaw. It is more apt than Mr Chisholm thinks: there is one piece missing, which I can only assume represents the Conservative party.

Today's debate has been constructive and the content has been very good. I hope that the ministerial team will take from my comments the broad context that the Scottish National party is onside with many of the objectives and specific measures of the white paper.

We want, however, to see much more done. I want to focus on a couple of key issues. The first is deprivation. We all-even the Conservatives-accept the link between poverty and ill health. We need to examine income distribution much more, and the have-nots in society, not just the overall level of wealth in Scotland. I hope that, in his summing-up speech, Iain Gray will answer the question about the absence of a Government target for dampness in housing, the cuts in the housing budget and the negative impact that that will have. If we want to believe in joined-up Government, it would be interesting to know why that target is not there and what the Government will do about it.

That brings me to resources. As we all know, the coalition is being kept together on the grounds that we need to find an extra £80 million from a whole series of budgets. I would like to quote not the white paper, but the green paper, "Working Together for a Healthier Scotland". It says:

"The combined problems of low incomes, unemployment, poor housing, a degraded environment, and high levels of crime impose an additional burden of ill-health on many families."

They place "extreme stress on communities, families and individuals."

I think that everyone would agree with that, but if that is the case, why will the Government be reducing the budgets for many of the areas which will impact public health? I understand that the health budget is to be ring-fenced, but what about the other budgets being cut? That will surely have a negative impact.

The other matter which we want to examine is that of local authorities, because much work is done in partnership. If local authorities' spending is falling, as it most assuredly is, that will also have a negative impact. Let us look at the whole picture in context.

On dental care, the minister correctly identified the position on the problem regarding under-fives. We need urgent action of course, but if we compare the target in the white paper with what went before it in the green paper, we see that the green paper mentions a target set in 1991 to reduce the incidence of dental disease in under-fives by 60 per cent. That target was meant to be reached by 2000. In the white paper, exactly the same target is set to be achieved by 2010. It is hardly ambitious; it is simply a restatement of an earlier target that was not reached. I understand that that is not purely the fault of this Administration, but is something that those in the former Conservative Government should take on board before they get too keen.

Another important aspect of dental care is covered by the SNP's alternative, as is the point about free dental check-ups being used to get the family norm moving by getting people to concentrate on preventive care.

On smoking, Hugh Henry told us that he was misled by the Daily Record. Perhaps he was not well represented-I dare say he will get a few allies on this side of the chamber. It is important to know where the Executive stands on this matter.

I associate myself with the remarks made by Dr Simpson. We need to examine seriously what he said on the need for urgent action and for taking more action than what the white paper proposes.

We also need to consider tobacco advertising.

I see that the white paper attempts to reduce passive smoking in the workplace, but gives no detail of what will happen. I look forward to the Government taking a much tougher line on that.

On the Conservatives'-correct-obsession with the situation surrounding drug abuse and misuse, the white paper calls for a concerted national strategy. That is what I thought Scotland Against Drugs was all about. It is a pity for us in the SNP that we are returning to a situation where the funding for tackling drug misuse is not ring-fenced as it has been before.

The Scottish National party welcomes what is in this document, but we want more focused resources and better targeting. We also want the appointment of a public health minister to ensure that public health is not allowed to slide down the agenda, as happened before.

Photo of Iain Gray Iain Gray Labour 4:50 pm, 1st September 1999

If we are to show how serious we are about dealing with the big issues in Scotland, we could not have begun today with a better subject. We have shown, during the debate, that we are serious about Scotland's health. After all, what could be more important than the health of our nation, especially when we have so far to go? We know that from one city or town to another-even from one street to another in those cities and towns-life expectancy differs significantly. For a newborn child that one statistic can mean as much as twice the chance of surviving to the age of 15. Such inequality cannot continue. When we talk of deprivation, what is it that our fellow Scots are deprived of? They are deprived of their health and ultimately of life itself. Of course, we must tackle the poverty and inequality that are at the root of those statistics.

Sadly, there is no of course about it. I am pleased that our debate has shown so much consensus. For almost 20 years the link between ill health and poverty and inequality was denied, in the face of all the statistics and facts. However, I am saddened that some of the speakers in the debate continue to try to deny that link or to say that addressing individual responsibility is somehow mutually exclusive with recognising that link. Those approaches are not mutually exclusive. I refer Mrs Scanlon to paragraph 129 in the conclusion to the white paper, in which individual responsibility is clearly flagged up. Saddest of all, though, was the fact that David McLetchie was not only unable to engage in consensus politics on such an issue but unable even to bear to watch someone else engaged in consensus politics. David, those are the old ways and everyone else has left them behind. I think that the Scottish people will leave you behind, as they have done already.

I cite one example of how ways of thinking must change. Several Conservative members, including Mrs Scanlon, have made efforts to move in the direction of consensus. Mary said that health spending is one third of our budget. This is the key to understanding the new approach: the health department budget is one third of this Executive's budget, but every budget is a health budget. I advise Tricia Marwick that that is why our budgets include measures such as the warm deal and other measures to improve Scotland's housing. That is part of our approach to the issue of health.

Photo of Tricia Marwick Tricia Marwick Scottish National Party

Will Iain Gray confirm that during its first three years this Labour Government will spend £176 million less on housing in Scotland than the Tories did in their last three years?

Photo of Iain Gray Iain Gray Labour

I confirm that by the end of our period in office we will have spent-if I remember the figure-£600 million more than the budgets that we inherited. We are investing hundreds of millions of pounds in order to build new houses and to improve our housing stock.

Photo of Iain Gray Iain Gray Labour

I should not take interventions in a summing-up, and I have already taken one.

To make the real difference we must pursue and develop effective partnerships. That is important. Those partnerships will include general practitioners. In the course of my duties as Deputy Minister for Community Care I have yet to find a focus group, but I have spoken to many GPs and I have visited their practices. They are at the centre of health promotion for us.

I refer to page 38 of the white paper where the role of primary care trusts and local health care is referred to specifically. The Executive is at the moment co-funding a study to provide guidance to improve early recognition by GPs of signs that might lead to suicide, which is a problem that we take very seriously. Access to learning disability nurses for each practice is a suggestion that I find attractive, but as you will know, there is a learning disability review under way and I expect that they will have a view on that, and we will take it forward. When it comes to general practice, what we are about is breaking down barriers between professions; we are not about promoting turf wars between different parts of our health service, as it seemed Mary Scanlon was doing at one stage.

We have to seek new and innovative ways of working to our common purpose. One reason for that is to maximise resources. The white paper pledges resources to this strategy, including resources for HEBS-there is no question of cuts in health promotion budgets. We could argue for a long time about resources, but I want to say two things quite quickly. We are investing £1.8 billion in our health services over the next three years because it is one of our spending priorities, and there must be priorities in spending. But I say to Phil Gallie, whatever the previous Conservative Government invested in the health service is essentially irrelevant because it did not work. The appalling statistics that we are discussing and that are referred to in the white paper are the statistics that we inherited from them. Perhaps-

Photo of Iain Gray Iain Gray Labour

Perhaps if they had acknowledged the underlying causes at the time, as both Robin Harper and Des McNulty said, you would have had more impact.

Most crucially, we must engage with the communities where the greatest impact must be made. Des McNulty and Robert Brown made that point. We will lay regulations in this Parliament to ban tobacco advertising. Yesterday I was in Wester Hailes, my own constituency, where over 40 per cent of people smoke. I was launching "Breathe Easy, A Guide to Stopping Smoking". It is a partnership between the Scottish Executive, Lothian Health Board, Edinburgh University and the local community health agency. It was produced by an expert, Irene Keltie, who lived in Wester Hailes, worked in Wester Hailes, smoked in Wester Hailes and gave up in Wester Hailes. It does not lecture but engages with the people it tries to address. That is the kind of innovation and partnership approach that we need to make what we are doing work.

When I left Wester Hailes Irene showed me the pages of names of people that she had signed up to the cessation programme in an hour. She said to me, "This is what it is about". It must be what we are about as well. The Parliament has the power to make the difference. The Executive is determined to pursue the delivery of this strategy across all departmental and other boundaries. We have a real opportunity today in this chamber to cut across our own traditional boundaries and stand four-square for better health, for a better life and more of it for all of Scotland's people. Let us take that chance.

Photo of Phil Gallie Phil Gallie Conservative

A genuine one. Two and a half minutes ago, before the minister sat down, I was advised that there was only one minute of his speech left.

Photo of Lord David Steel Lord David Steel Presiding Officer, Scottish Parliament

If you had intervened it would have been longer.