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Miss Kirkbride: Tobacco consumption is going up.

Mr. Milburn: The hon. Member for Bromsgrove (Miss Kirkbride) says, from a sedentary position, that tobacco consumption rates are rising. I am afraid that that is the factual inaccuracy peddled by the hon. Member for Woodspring in our debate on Monday. Although consumption rates were certainly rising for smokers overall right up to the point when the previous Government left office, the latest figures suggest that tobacco consumption is now falling. I believe that the measures that we have taken and that we plan to take--most notably the banning of tobacco advertising--will help protect the people who are most vulnerable to the dangers of smoking in the future. Those are young people, children and teenagers.

Underpinning all of our efforts to improve public health is the Government's commitment to address the causes of poverty that condemn so many to poorer health and shorter lives. This debate is about the public health agenda. The greatest public health challenges facing our country will never be addressed unless we deal with their fundamental causes--poverty of income and aspiration, lack of educational attainment and employment, and discrimination and social exclusion.

When we came to office, one child in five lived in a household where no one worked. Three million working-age people were out of work and had been dependent on benefits for two years or more. Four million children were living in poverty in 1995--three times the number 20 years before.

The health gap had widened too. In the late 1970s, death rates were over 53 per cent. higher among men in social classes 4 and 5 than among men in social classes 1 and 2. By the late 1980s, the health inequality gap had widened to 68 per cent. [Interruption.] The hon. Member for Bromsgrove thinks that that is something to smirk about--

Mr. Deputy Speaker (Sir Alan Haselhurst): Order. We cannot have a running conversation from a sedentary position.

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Mr. Milburn: We all know the Conservative position on issues of poverty and inequality. The hon. Member for Woodspring summed it up when he said:

Poverty might be boring for the hon. Gentleman and other Conservative Members, but it is a sad fact of life for very many of our constituents. It has direct health implications. We shall not make the progress towards securing the healthier nation that we want until we secure a fairer society. That is what the Government are committed to--opportunity for all, and improving health for all. We are making new investment in health services, in prevention as well as treatment, and new vaccination and screening programmes. All of that is coupled to the Government's national crusade to end child poverty in a generation.

That is the path to better public health, and we are making progress along it.

8.13 pm

Mr. Nick Harvey (North Devon): I welcome this opportunity to debate important issues of public health. Taken together, they constitute an agenda that should be the starting point for health debates in the House more often than is generally the case.

Although public health in Britain has improved over a long period of time, there is still a great deal to be worried about. Britain has the highest number of underweight babies in Europe. According to Government figures, there are 1 million children living below the poverty line who do not qualify for free school meals. Fuel poverty is still a problem too. According to latest figures from the National Energy Association, 8 million households cannot pay for the warmth that they need. Finally, the UK has the highest teenage pregnancy and birth rates in western Europe.

I welcome the NHS plan's attempt to address public health, and particularly the fact that there is to be more screening, although I believe that that needs to go even further and that more resources should be made available for capital expenditure in new technology. I also welcome the work of primary care groups and primary care trusts in identifying and registering those who are at greatest risk of ill health, and also the setting of national health inequalities targets.

It bears repeating that the state of public health depends on much more than just the state of the national health service. Much public policy in other Departments has a significant impact on public health outcomes. Equally, however, Britain's record on public health cannot be divorced from the state of the national health service. Many of our health problems stem from under-investment over a long period of time.

Many avoidable health problems have been exacerbated by a lack of nurses, and the lack of a co-ordinated public health programme that could have prevented many of the problems that the NHS has struggled to deal with. It is worth remembering that the number of nurses recruited fell from 37,000 in 1983 to 6,000 in 1995.

Other factors over the period also give cause for concern. In 1979, there were free sight tests, but people now pay £17 or £18 for the tests. Dental charges have risen 400 per cent. since 1979. Both those changes present significant barriers to health for those most in need of it--the poor. However, the charges make little significant contribution to the Exchequer.

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As I say, many other factors beyond the immediate issues of the health service make an impact on public health. For example, the doubling in the crime rate, the disastrous public transport privatisations and deregulations, and the refusal--until this week--to implement a tobacco advertising ban were all significant public health failures of the past 20 years. It is only by addressing such background issues that we will bring about a significant improvement in levels and standards of public health.

I noted earlier that Britain has the highest rate of underweight babies in Europe, at 7 per cent. Lord Patel, a gynaecologist, says that he has

Low birth weight has also been linked to adult diseases such as hypertension, heart disease and diabetes.

The Government should commission research into what constitutes a healthy income. Historically, rates have been based on political expediency, rather than on scientific principle.

Another concern has to do with school nurses, and the availability and quality of school health education programmes. We need at least another 500 school nurses, as teachers cannot be expected to provide health care as well as education. Dedicated expertise is required to meet the needs of the school-age population. In addition to the other postcode lotteries, we have a postcode lottery of health education. There must be a radical shake-up of the system, with better partnerships between the NHS, social services and local education authorities to ensure total availability to schools and their pupils of nurses and health visitors.

Liberal Democrats want there to be a statutory right for every child to have access to an independent health professional. We also want every school to have a named health professional provided through the local primary care group or primary care trust. In due course, we should like to see the creation of a national service framework on school health, with benchmarks and targets for improvement.

According to the Government's own figures, there are 1 million children living below the poverty line who do not qualify for free school meals. That is a cause for alarm, and it must constitute a priority for action. We support the Government's free fruit scheme for four to six-year-olds, but we hope that there will be scope to expand it to include older children. Malnutrition is a significant factor in health inequalities. Good eating habits and health education, supported at school, are vital.

Health inequalities must surely be one of the greatest concerns to all those with a sincere interest in public health. In the United Kingdom, people are twice as likely to die early in the poorest areas as in the richest, according to the UK Public Health Association.

Dentistry charges also promote inequalities. Access to NHS dentists is declining in many areas, as dentists drop out and move to private provision only. We believe that there is a need to do everything possible to bring more dentists back for at least part of their time into the NHS, to protect the poorest from ill health.

We also think that more help is needed in particular areas on the issue of water fluoridation, particularly in the light of York university's findings on its benefits.

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Areas with fluoridated water, either natural or added by the water companies, show as little as half as much tooth decay as areas without.

Dr. Fox: Would the hon. Gentleman go all the way with that view? Is it his party's policy to recommend fluoridation throughout the United Kingdom?

Mr. Harvey: We think that fluoridation should be available and that it should be a matter for local decision. There are great natural differences in the water in different parts of the country. That provides a logic for there being local decisions. Local authorities should have a greater responsibility for public health and should be the bodies to take responsibility for it, if need be by taking account, through a referendum or by other means, of the wishes of the local population. We certainly believe that fluoridation should be available as an option in all areas throughout the country.

It is also very important for eye check-up charges to be abolished. There is no greater impediment to making any improvement in public health than charging people for basic, routine tests which should be provided free as a matter of course.

I mentioned that fuel poverty is still a real problem. According to the latest figures, 8 million households cannot afford to pay for the warmth that they need. One in five lone parents reports damp affecting his or her children's health, and 22 per cent. of lone parents have no central heating. These are important factors determining health outcomes.

In 1998 there were far more extra deaths due to temperature drops in Britain than in the rest of Europe. In the UK, there was a 31 per cent. increase in deaths in the winter compared with the rest of the year, whereas the figure was only 14 per cent. in Sweden, 10 per cent. in Norway and 12 per cent. in Germany, according to House of Commons Library figures. Those are serious factors that have a real impact on health outcomes. Ending fuel poverty would mean fewer visits to GPs, fewer hospital admissions and fewer prescriptions.

The UK has the highest teenage pregnancy and birth rates in western Europe, with birth rates twice those in Germany, three times those in France and six times those in the Netherlands. The Government aim to halve those rates by 2010. That could be viewed as unambitious, but without proper co-ordination, and particularly the involvement of authorities on the ground at community level, I think that they will struggle even to meet those targets.

Evidence shows that some groups of young women are more likely than others to become pregnant: women from large families, those in lower socio-economic groups, those in families headed by lone parents and those with low levels of academic achievement. Resources, therefore, obviously need to be targeted and channelled effectively.

Some areas have rates of teenage pregnancies five times higher than those in other, more affluent areas. There is specifically a comparison between the Southwark area and the Chilterns. These figures are sometimes compiled by local authority ward, and there was a point in the mid-1990s when a local authority ward in my constituency--this may strike people as improbable and

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cause raised eyebrows--had the highest teenage pregnancy rates in the country; higher than any inner-city area, for example. So the matter is not as simple as identifying certain big cities that need to have all the money ploughed into them, while other areas--typically rural areas or southern areas--may be assumed not to need it. That is a long way from the truth. The facts are rather more complex. We must look at the wider causes, and all the agencies dealing with these age groups will need to be involved.

The burden of sex education should not always fall on teachers, some of whom will not be best qualified to give advice on these subjects. The Secretary of State mentioned that he hoped very much to bring out his sexual health strategy within the next couple of months. I welcome that, although it must be said that it seems to have had an extraordinarily long gestation period. I hope very much that when it comes it will tackle the issues involved head on. [Hon. Members: "It may be an elephant."] The gestation period might imply that, but I hope that it will be rather more nimble and fleet of foot and will not kowtow to those in certain elements of the tabloid media who seem able to whip themselves up into a state of frenzy about the very things that are most needed to tackle some of these complex issues. Those countries that take a more progressive approach to these matters seem to have the best outcomes. I hope very much, therefore, that the target audience will not be the editorial writers on some of the newspapers to which I have referred.

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