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Westminster Hall

Thursday 13 December 2001

[Sir Alan Haselhurst in the Chair]

Public Health

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Caplin.]

2.30 pm

Mr. David Hinchliffe (Wakefield): I am grateful for the opportunity to raise the matter of the Health Committee's report on public health, which was issued in the previous parliamentary Session. Today's debate is timely. Hon. Members may have seen press reports of the latest confidential inquiry into maternal deaths, which stated that women in the most disadvantaged groups in the United Kingdom are 20 times more likely to die in childbirth than women in the two highest social categories. Those are worrying figures and it is right to spend some time on the subject of health inequalities.

The debate takes place against the background of several public health worries. I have expressed concern in recent weeks about the narrowness of political debate on health, in the Palace of Westminster and elsewhere. We have tended to tie the debate down to waiting lists, waiting times, targets, pledges and the number of doctors, nurses and beds. We have compared the proportions of GDP spent by different European countries and the UK. Our view has been specific and narrow, and I welcome the opportunity to look at the bigger picture today.

It struck me that the anti-poverty measures announced in the autumn statement by the Chancellor of the Exchequer would probably have more of an impact on health than the health measures that he announced amounting to £1 billion. Public transport improvements, and this week's announcement on transport funding, are also relevant. Reducing vehicle emissions and enabling more people to use public transport makes more sense than employing more specialists in chest disease to treat childhood asthma, which has increased to a worrying level. In the Committee's view, a wide perspective is better in evaluating health issues than the narrow confines to which debates in this place usually adhere.

The second factor that is relevant to today's debate is the impact on public health strategies of the current major structural change in the national health service. I find the pace of change phenomenal. Four separate formal consultation processes on changes in the national health service are under way or about to begin in my constituency. I broadly support the direction in which matters are being taken, but we must accept that the pace of change creates questions and problems. One matter of concern is the location of the public health function. I welcome the creation of strategic health authorities and primary care trusts, but the location of public health in the new framework is a cause for concern.

We began the inquiry in May 2000 and our report was published on 28 March 2001, with a Government reply in July. Our inquiry was undertaken in response to

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several factors, including Government initiatives on public health: health action zones, employment action zones, the Health Development Agency, health improvement programmes, the Acheson inquiry on health inequalities and, of course, the first appointment of a Minister for Public Health. We wanted to assess whether the Secretary of State's rhetoric that the time had come to take public health out of the ghetto was substantiated by the Government's action on public health. We wanted to consider the subject so that we could respond to feelings expressed by many that public health had been marginalised and lacked any strategic direction. People were concerned about the fact that the strategy of the Department of Health was still dominated by the medical model rather than the social model. The Health Development Agency stated in the evidence that

We all accept that, and it is important to see how the Government develop their wider strategy to take account of those arguments.

I want to express the Committee's thanks to several individuals, including the many who submitted the written evidence that formed the basis for many of our discussions and oral hearings. I also want to thank our witnesses, many of whom gave extremely relevant evidence that helped the inquiry. I express my appreciation to all those who were involved in arranging our visits. We made several illuminating visits in the United Kingdom, including to Cornwall and Scotland.

We also went to Cuba. The Opposition are currently travelling around Europe in consideration of their health policy. If they have a chance to board a plane for Cuba, I recommend it, as I left Cuba impressed by its health system and, to be honest, every aspect of the system there, which surprised me. Many lessons can be learned from the Cuban model. Despite a background of third-world poverty, it has health outcomes that are comparable to those in western countries such as our own. I thank the Government of Cuba and the colleagues there who made our visit so successful and useful.

I thank our specialist advisers and first-class staff, who serve us well. We do not have many staff, but they are of the highest quality, and I appreciate their support.

Perhaps I will be forgiven for paying tribute to three Committee members who were involved in the inquiry but who are no longer in Parliament. Our good friend and colleague John Gunnell, the former Member for Morley and Rothwell, was not in the best of health and struggled on occasion. Despite that, he was a consistent hard worker on the Committee and went on the visits to Cuba and elsewhere. I and all other members of the Committee appreciated his advice and wise counsel. I miss the advice of Dr. Peter Brand, who was the Member for Isle of Wight and lost his seat at the election. We did not always agree, but he was the best of company and had a detailed knowledge of the health service. We have missed that knowledge in Parliament since he left. Eileen Gordon also lost her seat. She worked hard on the inquiry and contributed a great deal to the success of the Committee's work.

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I come now to the detail of the report, and specifically to health inequalities. Research by a range of experts shows that health inequalities have increased during the past 20 years. The Acheson independent inquiry into inequalities in health stated:

That is an indictment of the policies—not health policy directly, but policies overall—that have led to those worrying changes.

Sir Michael Marmot, a public health expert, gave evidence during the inquiry. He told us that different causes explained the changes. Some will be determined by health status in childhood, but less tangible factors such as the amount of control that one feels over one's environment, which in turn relates to one's position in society, affect physical and mental health. Our report states that he explained:

We should take close note of his strong evidence. We recommended the incorporation of health inequality targets into the health improvement programme and the community plan, to give it bite and clout. We are pleased that the Government have accepted our suggestion that what we term baskets of intermediate targets should be created for each of the headline targets. We also recommended that each Government Department should have a public service agreement to conduct health audits. We note the Government's more cautious acceptance of that, but feel that it is a good initiative that could be taken further.

The Government seem to have introduced a plethora of initiatives somewhat unsystematically and with no clear strategy as to how they might inter-operate. The theme of initiative overload arose frequently in both oral and written evidence to the inquiry. We wrote that

That lack of coherent strategy reflected more profound systemic and structural problems caused by a lack of co-ordination between Government Departments, strategy agencies, elected authorities and the voluntary sector. We also noted an apparent cooling of the Government's enthusiasm for structural reform. We argued that the NHS plan apparently marginalised public health and we were dismayed by the repeated delays in publishing Sir Kenneth Calman's report on the public health function.

We felt that there was much merit in Professor Sally McIntyre's suggestion that area-based interventions should be subject to more rigorous analysis and we are pleased that the Government are following up that initiative. We remain unconvinced that area-based initiatives engage the communities that they serve, and nothing in the Government's response convinces us that they have a clear strategic role in mind for Health Promotion England and the health promotion function. We were impressed by the Health Development Agency, which we should like to see resourced more

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appropriately. We were also persuaded by the evidence from Sandwell and Hillingdon health authorities that the health improvement programme and community plan should be more closely integrated. We are delighted that the Government accepted that that would be advantageous.

We urged the Government to establish new partnerships in the form of local strategic partnerships and were delighted to see that they accepted that recommendation also.

In part of my constituency, the two primary care groups are considering the establishment of either one or two primary care trusts. I am concerned as to whether the two PCTs could fulfil the public health function separately in my constituency or elsewhere. We voiced our grave concern in the report that primary care providers lacked the capacity to take on the public health function. Nothing has occurred since our report was published to mitigate that concern. It is a crucial problem. There is a danger that the combined effects of the culture in which health professionals work—the "fix and cure" and "beds, doctors and hospitals" models—a lack of proper career opportunities in public health medicine and a general pressure on health professionals will submerge public health.

We talked in the report about shifting local emphasis to empower a professional whom we saw to be underused—the health visitor. I am glad that my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) is not present, because she thinks that I am obsessed with health visitors. However, when I was a social worker in the early 1970s, before the Heath Government removed the health function from local authorities, I worked extremely closely with health visitors and observed the extremely valuable role that they played in dealing with child protection issues and other problems in the community. The Committee shared my view that we should press for better use of those professionals, who have achieved a lot in the past and have tremendous potential for the future.

We also argued in the report for greater co-ordination between health visitors and school and community nurses. We suggested that PCGs and PCTs should be required to have an additional designated local authority officer with a broader public health remit. That is not the first time that the Committee has called for closer links between local authority and health authority functions, and we are heartened that the Department of Health

We hope that the growth of care trusts will foster a culture of greater co-operation, although there are clearly great uncertainties at present.

The Committee also recognised that the shift from 100 health authorities to 300 PCTs would challenge public health capacity and raise questions about collaborative work between PCTs across their patches. I received a copy of a letter dated 4 December that the Association of Directors of Public Health sent to the NHS chief executive, Mr. Crisp. It welcomed Lord Hunt's endorsement of a strengthened public health function in a speech on 13 November. However, it continued:

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That important point reinforces our concern about the role of the strategic health authorities and the position of PCTs. Interestingly, the association proposes that a director of public health at strategic health authority level should lead a small team that is responsible for performance management. I raised the issue with the Secretary of State when he came before the Committee a few weeks ago, and he recognised health inequalities as a key issue for the new strategic health authorities. I cannot say whether the Committee would endorse the call for a director with a small team, but I think that it makes a good deal of sense in terms of ensuring that PCTs across the board take that important issue seriously in their patch.

Dr. Evan Harris (Oxford, West and Abingdon): The hon. Gentleman makes an interesting point about the system's inability to deal with public health. The report was written when there was no sign of the structural change that would abolish health authorities. The NHS plan has been published, the Committee has done excellent work and everyone has set out to tackle the problem, but we now find that half the organisations involved will be abolished and their staff will have to spend much of their time finding a new job. Does the hon. Gentleman agree that that is unfortunate?

Mr. Hinchliffe : The hon. Gentleman was not here when I referred to the pace of change and to my concerns about the issue that he raises. I have had discussions with the Secretary of State, and I am encouraged that he and the Minister recognise that it is crucial for the strategic function to be appropriately located.

It might help if hon. Members consider what is happening in their areas. This week, knowing that this debate was coming up, I asked the director of public health in my area for his views on the role of the strategic body. I think that he would endorse the concern expressed by the Association of Directors of Public Health that there should be a clear handle on public health at that level and that PCTs' work should be properly monitored. Those that do not perform appropriately—I worry that that may be true in parts of Yorkshire—should be reminded, assisted and, indeed, made to perform appropriately on such an important issue.

To return to the role of local authorities, it is fairly common knowledge that my agenda includes a much stronger role for local government in health issues. So far, I have been unable to persuade the Secretary of State or the Prime Minister of my views, but I am working on it.

Andy Burnham (Leigh): There is time yet.

Mr. Hinchliffe : There is time yet, as my hon. Friend says. As a young social worker before 1974, I worked in a local authority that had a health department. It had a more obvious organisational framework than we have now. I worked in child protection, care of the elderly and mental health, and that framework made much more sense. As a young councillor, I also served on a public health committee. I worked with the local medical

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officer, who used to attend our committee meetings. He had clear targets and challenges on issues such as smokeless zones, slum clearance and inoculation of children. This might sound old hat, but the old Ministry of Health created a much healthier society than would otherwise have been the case. I favour a stronger role for local authorities. The Committee debated long and hard whether we should retain the current arrangements or move the public health function back to local government lock, stock and barrel.

Mr. Oliver Heald (North-East Hertfordshire): I am following closely what the hon. Gentleman is saying. Does he agree that the Government's reply on coterminosity and joint appointments for directors of public health makes it hard to see exactly what model they favour? Some of those issues need to be resolved if we are to have a clear and understandable framework for public health.

Mr. Hinchliffe : Yes, I agree. Our difficulty was recognising the lack of coterminosity. I do not want to be partisan, but the Conservative Government have a great responsibility for that lack. I wish that the present Government would turn the wheel the other way, but the latest changes do not take us back in that direction. The Minister may respond to that point, because she may have a better idea of what the Government meant by their response.

Local authorities have as important a role as they did in the past. They are still responsible for air quality, environmental health, food hygiene, leisure services, education, planning, safety and transport; all those policies are directly related to public health. We welcome the recognition, widely expressed in evidence to the Committee, that public health should be at the heart of local government, and we have recommended that health should be a key element in the local authority community plans. We were pleased that the Government were considering ways in which the health improvement programme and the community plan could be more closely aligned. I hope that the Minister may have something to say on that.

Somewhat reluctantly, however, we concluded that major structural upheaval in the location of the public health function was not the answer, but that incentives needed to be created to ensure that the function delivered across the entire health system, wherever it was positioned.

I turn to development in the community. One or two hon. Members who were not members of the Committee may know that we were impressed by a scheme that we visited in Cornwall. The Minister—not my hon. Friend the Member for Salford (Ms Blears), but the then Minister for Public Health, my hon. Friend the Member for Pontefract and Castleford (Yvette Cooper)—visited the Penwerris estate in Falmouth in Cornwall to see the remarkable achievements there.

For those who are not aware of the scheme, it is a beacon project based at a housing estate in Falmouth, the poorest ward in Cornwall. It had serious social problems and vandalism, joy-riding, drugs and teenage pregnancy were all rife. A scheme emerged that was fronted by Hazel Stutely, a health visitor who I gather now works for the Department; I commend the

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Department on making use of her expertise. She managed to combine the commitment and collaboration of all local agencies to tackle those problems collectively. We saw listening forums engaging with the local community, bringing people on board who were alienated and who thought of the authorities and agencies as enemies rather than friends.

That group achieved a remarkable turn-round on that estate. Post-natal depression decreased by 80 per cent. and a 60 per cent. reduction was achieved in the number of children on the child protection register. The child accident rate halved, as did the crime rate. Boys' results in standard assessment tests improved by 100 per cent. Generally, we saw a happier environment where previously there were many serious problems.

We were impressed by that scheme, not least because it illustrated that such initiatives must engage with local communities and that they should derive their energy from the bottom up rather than from the top down. We learned a big lesson. We can go in with all sorts of schemes at the top, but unless we get people at the bottom—the key people—working well we may be wasting our time. I welcome the fact that Mrs. Stutely passed on her ideas to other areas, and I hope that they use them.

In order to assist local authorities, the Government should review the bidding system to ensure that it is more equitable and efficient. We have looked at this question before and considered the work of voluntary organisations and local groups. It has been difficult, but we appreciate the Government's positive response to our recommendation.

A critical part of our inquiry was into the role of directors of public health. We gained the strong impression that the role had diminished in authority over the years. Strong supporting evidence—which frankly surprised us—came in the disclosure that some directors of public health did not attend the annual review of their health authority. That is an increasing trend. Some 56 per cent. of those surveyed attended meetings in 1998, but only 43 per cent. did so in 2000. Moreover, at half those meetings, the key annual report on public health was not even discussed. Some excellent information is contained in those reports, as hon. Members will see if they read them, and it worries me that while dust gathers on them, not much is done. One of our tasks is to ensure that they are taken seriously.

Overall, we concluded that directors of public health were not currently providing the necessary leadership on public health. To strengthen his role, we recommended that the annual report should form a key part of a combined community and health improvement programme. It should form a consistent format to allow a comparison between areas, and it should include contributions from other stakeholders in statutory local and voluntary organisations. We felt that more effort needed to be made to promote joint health authority and local authority appointments, even in those areas where coterminosity did not apply. We especially endorsed a suggestion from Ken Jarrell that, as well as being jointly appointed, directors of public health should be jointly accountable, thereby creating a link that is frequently lacking at the moment.

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The Committee spent some time considering the issue of physical activity and sport. Hon. Members may have noted the recent National Audit Office report on overweight youngsters. The number of obese 15-year-olds has more than trebled in the past decade. We found that fewer than a third of schoolchildren devoted two or more hours a week to physical activity—well below the levels found elsewhere in Europe. There is probably a connection with the fact that our national sports teams do not do very well. Sport has fallen off the agenda in schools.

I congratulate the Yorkshire Post on running a campaign called "A sporting chance", which highlighted the fact that schools were not ensuring that youngsters received basic opportunities to play sport. We were impressed by the way in which sport is linked to health in Cuba. That is such an obvious connection, but one that we fail to make. The former Minister for Sport my hon. Friend the Member for Vauxhall (Kate Hoey), gave evidence to the Select Committee, and we were surprised to hear that there was no formal connection between local initiatives on public health and on sport. Healthy living centres are an obvious example of how that connection can be achieved. In my constituency, one rugby league club hopes to have a healthy living centre based at its clubhouse.

We gave the Government the benefit of the doubt in agreeing that responsibility for sport should remain with the Department for Culture, Media and Sport, but we are heartened that the Secretary of State now sits on the ministerial committees that consider home and social affairs and health strategy, which accords with one of our recommendations. I was delighted to see in the press a few weeks ago an interview given by the current Minister for Sport, in which he emphasised his role in the health of the nation and the connection between sport and health. To be fair to the Government, they have taken up some of our recommendations.

Mr. Gareth R. Thomas (Harrow, West): Does the hon. Gentleman also accept that another crucial area of work for the Health Development Agency relates to anorexia and eating disorders? Sport is relevant to that issue, but a more holistic approach is required, perhaps with more funding and a higher profile, which the HDA might be able to help solve.

Mr. Hinchliffe : That is an important point. My hon. Friend is probably unaware that when the Health Committee considered mental health, we identified eating disorders, which are not a direct mental health consideration, as one area in which the organisation left a great deal to be desired. The hon. Gentleman's point is valid.

Before I conclude, I would like to focus for a moment on the location of the public health function. Having recognised that public health was about far more than just the health service, we spent considerable time considering whether public health policy should remain with the Department of Health. We considered many alternative locations, including the Cabinet Office.

We did not accept the view expressed by some that the status of the Minister in charge of public health had been downgraded simply because my hon. Friend the Member for Pontefract and Castleford now holds the more junior title of Under-Secretary, whereas my right

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hon. Friend the Member for Dulwich and West Norwood (Tessa Jowell) was a Minister of State. Bearing in mind that the accountability structures in the Department mean that Ministers are directly accountable to the Secretary of State for Health, we did not feel that that represented a downgrading.

We heard strong arguments on all sides for and against shifting the public health function out of the Department of Health altogether, to free it from the domination of the medical model, which some consider to be inevitable. We concluded that, rather than implementing change for its own sake, it would be better to promote greater cross-departmental working. We are pleased that the Government are making some progress on that, but unless public health achieves the priority in Government that we believe it deserves, calls for the function to be taken out of the Department of Health will inevitably grow.

In terms of the priority given to public health, I am sure that I reflect the Committee's view in expressing my deep disappointment that, despite many welcome policy initiatives to reduce smoking, legislation to ban tobacco advertising did not appear in this year's Queen's Speech. I hope that that measure, probably the most fundamental public health measure of all, will be brought before the House soon.

I have gone on for some time, and I am pleased to see that so many other hon.Members want to contribute. We still need to learn the lessons of the great advances of the 19th century. I recall years ago studying the work of Edwin Chadwick and his remarkable achievements in public health. I recall that he argued for a key role to be given to the district medical officer—as he was then called—to supervise improvements in sanitation, the workplace and the physical environment. I would argue that the zeal, energy and authority of district medical officers must be recreated. That will happen if local government and the health service co-operate more closely.

To end on a more positive note, the Government deserve some praise. Sir Michael Marmot and Sir Donald Acheson drew attention to the aggravating effects of relative poverty on public health. I am heartened by the recent report of the Joseph Rowntree Foundation that, for the first time in four years, the number of indicators of poverty that have improved has exceeded those that have got worse. As I said at the beginning of my speech, tackling issues such as relative poverty, education, housing and social services will have more impact on public health than changes in the health care system.

3.2 pm

Mr. David Amess (Southend, West): I am very impressed by the turnout of hon. Members. They have shown great interest in our report. The hon. Member for Wakefield (Mr. Hinchliffe) and I are the only two survivors who participated in the report able to be present today, but it is gratifying that so many Members are interested.

As one who is not entirely content with the way in which Parliament has moved, I think that our Select Committee structure is splendid. All members of Select Committees say this, but the Health Committee is a particularly strong one. It comprises 11 different

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characters. We do not always agree, but we spend our time well, and the fact that we produce such good reports is in no small measure due to the excellent leadership of our Chairman.

The Committee issued its press notice—not at my suggestion—in response to the annual LSE health lecture given by the Secretary of State on 8 March 2000, when he stated that

The Committee wanted to see whether the Government would deliver on that speech—that it was not merely rhetoric. It is far too early to come to any conclusions about that, but it was the speech of the Secretary of State that prompted the Select Committee to undertake the inquiry.

I shall not bore the House by mentioning again aspects of the Committee's work already covered by the hon. Member for Wakefield, but I shall talk about Cuba presently. I viewed our experiences there entirely differently from the hon. Gentleman. We visited some very interesting schemes elsewhere, including one in, I think, Newcastle.

I am not sure whether the House realises that the Health Committee has a unique guessing ability. Little did we know, as we prepared the report, that within a month structural reforms would be announced. Government announcements in the following weeks featured many of our recommendations, so I suppose we can in a way take credit. I know that hon. Members who took part in the inquiry—three of whom are present—were very pleased.

I want briefly to mention the role of school nurses. The Minister was not in office at the time of the inquiry. The Under-Secretary of State for Health, who I believe is on maternity leave, gave evidence. She and I had an exchange about the role of school nurses. During my time as a teacher I found that what they did was invaluable, whether checking heads for lice, showing children how to brush their teeth properly without pushing the gums up or a range of other work. That is why I am pleased about the Committee's recommendations.

The relevant paragraphs of the report—185 to 188—show that we were concerned that the traditional role of the school nurse had shifted away from the provision of health screening towards a more strategic public health role. That may be splendid, but most of my children are still at school and my gut feeling is uncertainty about whether the sort of support most parents would want is available. For instance, I challenged the Minister to come up with a cure for head lice. It is an embarrassing subject, but having them does not mean a child is dirty; children just catch them. She kindly sent me all the Department of Health literature on the issue. Unfortunately, many schools in my constituency still have outbreaks. Could it be that the nurse used to carry out the revolting job of checking for head lice, but now more people have them? It is very expensive to purchase all the chemicals. It is even possible to give the lice electric shocks through special combs, but apparently they resist those too. The matter is an important one.

Asthma is a real problem for children. One has only to go to a head teacher's office and open the cupboard there to see many different appliances for dealing with asthma fall from it. I do not have a simple answer. Is air

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pollution the cause? I do not know. We can all see that a problem exists. Another condition from which many children seem to suffer is epilepsy—this may, I suppose, be special pleading, as one of my children, aged 13, has it. It is a particularly difficult form and it seems the medication cannot be got right. We touched on it in our inquiry and I should be interested in the Minister's comments. She may want to write to me on the subject.

School nurses are an underdeveloped resource. The Community Practitioners and Health Visitors Association highlighted this concern. We suggested that the employment structures of school nurses should be rationalised to allow effective joint working and partnerships—my goodness, I am coming out with new Labour-speak, but I am sure that the Minister understands what I mean. The Committee also thought that the Government should support and consult the professional bodies to develop school nursing services as a vital public health service. It would be beneficial if this service could be integrated with other public health services in the community.

The hon. Member for Wakefield touched on the recommendation that PCGs and PCTs should have a designated officer from the local authority with a broad remit for public health. I had a meeting with my local authority on Monday, and we will be getting a dedicated officer. Can the Minister advise me whether the appointment of such officers will be according to a local authority's resources, or will it be a requirement to have a dedicated officer? Such officers would be useful if PCTs are to achieve their targets. The hon. Member for Wakefield was right to emphasise that the Committee thought that the current role of the director of public health was too vague.

My final point—I shall mention Cuba—concerns sport. If everyone in the United Kingdom were living a healthy lifestyle, we would not be spending huge sums on the national health service. As a Conservative Member, how can I call on the Government to develop a nanny state that tells people not to do this and that? Nevertheless, I implore the Minister to see whether more can be done in terms of sport.

The former Minister for Sport, the hon. Member for Vauxhall (Kate Hoey), gave evidence to the Committee. She gave a splendid account of herself, but I felt that her hands were tied. I gained the impression that Departments were not working together, and she felt strongly that the Department of Health could do more. I know that the hon. Member for Wakefield has spoken about the adviser, which is welcome, but I wonder whether the Government could do more. I had a wonderful briefing from the Central Council of Physical Recreation and Sport England. They tell me that the Treasury spends £750 per person on health care, but only £1 per person on sport. Some people would say that that is right, but the difference seems huge.

The hon. Member for Wakefield mentioned children. We have many lazy children, including my own, in this country. Young people found out what their legs were for only during the petrol crisis. Some children are so lazy that when they are dropped off at school they virtually want the cars to be driven into the classroom. Older people set younger people an example by not wanting to be driven everywhere and by being prepared

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to walk. Considering the terrible trial that concluded yesterday, I am not suggesting that young children, who are vulnerable, should be left to walk alone; I am simply making the point that we, as a nation, could do more to encourage our children to participate in sport.

Sport England is concerned that the Government are not promoting sport across the Departments and highlights some alarming statistics on coronary problems and cardiovascular and respiratory diseases. For example, 37 per cent. of deaths from heart disease can be attributed to inactivity.

The hon. Member for Wakefield mentioned obesity. All hon. Members will have been sent reports on that growing problem. When Edwina Currie was a health Minister, she took an individualistic approach to various aspects of people's lifestyles. Some of the messages that she gave out had an element of common sense, although a few of my hon. Friends thought that she could have used slightly more diplomatic language.

Hon. Members always draw on their own family circumstances. My 90-year-old mother tells us that she goes to keep fit classes once a week. We are not sure exactly what she does there—perhaps they all sit on chairs and touch their toes, or just chat to one another. The quality of the residential and nursing homes that we visit in our constituencies varies considerably. It would be a good thing for the Government to encourage older people, especially those who are recovering from health problems, such as strokes, to do some sort of physical activity.

The CCPR believes that partnerships should be established between PCTs and voluntary sports clubs, that voluntary sports clubs and dance classes should play a key role in exercise referral schemes, and that all schoolchildren should have two hours of curricular physical education a week. I know that many children hate sport and do not want to do it, and we do not want to make them unhappy or see them bullied, but we should encourage them to engage in as much physical activity as possible.

I am heartened that so many hon. Members are here to express their interest in the report. There is nothing so frustrating as working hard on a report only to find that no one takes any notice of it.

The hon. Member for Erith and Thamesmead (John Austin), who has just joined us, was one of my colleagues who thought that it would be a good idea to visit Cuba. In making these remarks I mean no insult at all to the Cuban Government. They could not have been more generous with their hospitality and it was a splendid visit. However, I was shocked by the condition of the country. I should not call it a dump, but I had no idea that half the buildings were falling down and unfinished. My constituents would be outraged if they saw the state of some of the hospitals and the working conditions there.

Mr. Hinchliffe : Some of us understand the background to the physical state of and appalling poverty in the country, which is partly due to the blockade and the difficulty of getting drugs. Does the

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hon. Gentleman agree that that makes it all the more remarkable that the health care system there has such tremendous outcomes?

Mr. Amess : I was about to come to that. The Cuban Government spend much less than we do on their health service, but people live for about the same length of time and there is about the same rate of infant mortality.

The Cubans' emphasis on sport is definitely an example that we could follow. They also have a good diet, mainly because it is a poor country. It is ironic that some of my colleagues and I became ill during the visit. Some of us are still engaged in correspondence with British Airways about who was to blame. British Airways blames it on our lifestyle in Cuba; I blame it on the rotten prawns that we ate on the flight back. Our visit to Cuba was worthwhile, but given its poverty I doubt whether my constituents would want its medical facilities to be replicated here.

This is a splendid report. I am sure that the Government will take it seriously, and I look forward to monitoring carefully how they deliver on some, if not all, of our recommendations.

3.19 pm

Mr. David Kidney (Stafford): I have never served on the Select Committee on Health, but I aspire to do so one day and I was delighted to read its report. In four years as a Member of Parliament, I have been closely involved with all my local health services, and in that time I have experienced the gnawing doubt that public health is not getting the attention that it should. I could not quite put my finger on those inadequacies, until I read the report. Reference has been made to the very sentence, in paragraph 40, that caught my eye:

Reading that was like watching a light being switched on; it summarises exactly what I think is wrong.

I congratulate the Select Committee on a superb report that puts its finger on the things that are wrong and how to put them right, and I hope that we develop a programme during this Parliament that follows the report like a route map. I want to illustrate the problems and my dissatisfactions by mentioning a couple of incidents that have occurred since the general election. A very senior public health professional came to me to ask what was happening to public health in the restructuring of our health service. It seemed a bit odd that the person in the front line—a professional with years of experience—needed to ask me about his future, his job and his role. That made it clear to me that something was wrong in public health.

The second example concerns a PCG health promotion officer—health promotion is a subject that interests me intensely—whom I visited to ask what she could do in our community. I was amazed to discover that she could not get the budget for health promotion from the local health authority, which was hanging on to the money and leaving her to do the job. As she could not get that money, she was unable to carry out her desired projects.

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The Health Development Agency might well appear impressive to the Committee, but in my time as an MP with an interest in public health and the promotion of healthy living, I have never heard from it. Health Promotion England has never told me about what it is doing, and friendly though my local health authority is—we co-operate closely—it has given me no answers on health promotion and the budget that it has hidden. I could get no action from my primary care group; it has not got the money.

I should point out that the health promotion officer whom I met was incredibly imaginative in her work. She developed partnerships and sponsorships and achieved much, but she found the situation terribly limiting, and now she has found another job. Doubtless she got fed up with scratching around, but I should make it clear that she was a marvellous officer. I should also make it clear that we have a very good local director of public health, and I exclude him entirely from criticisms of the local health community.

Thank goodness that the report calls for clarity of roles, effective presence and partnerships that deliver for their local communities, because that is precisely what we need. We can get it right, and I shall give two further examples. Nationally, the smoking cessation programme has been a great success, offering a marvellous example for us to follow in future. According to the CCPR briefing, exercise on referral is a growing phenomenon at a local level. GPs in my area have come together to refer people for exercise programmes such as keep-fit classes and gymnastics courses, which the local authority provides through its recreation centre. That is another example of effective and successful partnership at a local level.

We need to tackle the other challenges that we face with the same effectiveness. This week, there has been much publicity about alcohol misuse, but despite our highly effective 10-year action plan to defeat drugs misuse, that dreadful problem remains. My experience at Stafford police station—I should immediately point out that I was not detained there—offers a practical example of why the drugs plan is not yet working effectively. Ours is one of three pilots in the country for the drug testing of people who have been charged with offences. I do not know whether it will surprise, shock or confirm the belief of hon. Members when I say that more than half of those offenders test positive for heroin or cocaine.

An arrest referral worker asks each offender if they would like some help with their drug misuse problem. Almost to a man or woman, they say, "Yes, please." There lies the problem. There are no services outside the police station to which they can be referred for treatment. By the time they have waited to get on to a course or get help from a counsellor, they have lost their resolve to solve the problem and they continue in the cycle of drugs misuse. The new integrated drugs and alcohol service teams in Staffordshire are finally up and running. I have great hopes for them for the future, but there are still problems in accessing sufficient resources to meet needs.

Other challenges include the unacceptably high level of suicide deaths and the unacceptably high level of deaths from accidents in the home and workplace. Deaths from such accidents are dwarfed by deaths on our roads. Mention has already been made of obesity. I

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include that as a challenge, because I recently raised it in questions to the Minister for Sport in the Chamber, and in writing. I am pleased to see that he chairs a ministerial committee that includes representatives from the Departments of Health, Education and Skills and Transport, Local Government and the Regions, as well as representatives from Sport England, the new opportunities fund and other co-ordinators. That has monthly meetings chaired by the Minister for Sport. Let us hope that strategic thinking about sport and health going together—something my hon. Friend the Member for Wakefield (Mr. Hinchliffe) called for—will arise from those meetings.

In the briefing from the CCPR, I was struck by the lack of resources, in terms of the £1 per head of spending on sport. On the other side of the coin, however, I was struck by the huge resources that could be mobilised if we wanted to. Mention was made of the 110,000 voluntary sports clubs in England.

That brings me to the main argument of my contribution today; the imbalance in spending between the Department of Health and private sector advertisers who advertise products that make people unhealthy. I have seen that argument used on the television recently. In the news report about the chief medical officer's report on alcohol misuse and death from liver cirrhosis, someone said that we could spend only £1 per head, compared with the thousands or millions of pounds that advertisers can spend. We should not mind that. I certainly do not call for the spending of more public money on advertising to try to get the message across.

Instead, the Department of Health should tap into the other resources available to match the advertising in a different way. Those resources include other Government Departments, such as the Department for Culture, Media and Sport and all the quangos that it can tap into, such as the HDA and Health Promotion England, and especially local authorities such as that of my hon. Friend the Member for Wakefield. I gave the example of the recreational centre. I find my local authority very keen to take part in joint health promotion campaigns and deliver practical help. The authority can reach the whole of its community, and if it does not have the experience itself, it knows someone who has. Local authorities are a huge resource that is not used enough on the health front.

Directors of public health are also key resources that should be used much more. My hon. Friend the Member for Wakefield mentioned their annual reports. Some of them are fantastic, and packed with useful information, but that never gets used for any good purpose.

Mr. Heald : I am listening with interest to what the hon. Gentleman says, especially about the way in which sports clubs could be used to develop the message of health promotion. Does he agree that one of the real problems is that there are not enough sports coaches with quality skills in coaching? Something needs to be done about that. Is the hon. Gentleman aware of the Sport England initiative—which the Government

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support and which Trevor Brooking has been fronting—designed to improve the number and quality of sports coaches? That sort of thing needs to happen.

Mr. Kidney : That is a good example and I am aware of it. We have just had the launch of Active Sport in Staffordshire. Sport England was represented and Tessa Sanderson and the Minister for Sport were there. We have money from the new opportunities fund and the Department for Culture, Media and Sport to promote sport in schools and communities and I am optimistic about that project. It is a good example of something that can be tied into health to meet challenges such as obesity. The Department of Health could use many resources to meet the problem of advertisers spending more money than it does.

"Voluntary groups" includes sports groups. The voluntary sector in Stafford is absolutely thriving and bubbling with enthusiasm. Many such groups could be used to help the campaign for health promotion in this country. A group that has been overlooked—I did not see it mentioned in the report—is that of employers and trade unions. One of the best places to get people's attention is at work, and employers and trade unions would be willing partners in delivering the message and helping us if they were given information to pass on. That just needs co-ordination.

Another valuable resource is Members of Parliament. I want to receive messages from the Health Development Agency and Health Promotion England and help them by taking part in their campaigns. My local authority and director of public health make full use of me; I have fronted many launches in Stafford, such as "health through warmth" and the exercise on referral that I mentioned. I have promoted such schemes, talked to other decision-makers and networked. I have been delighted to carry out that role. I bet that the other 658 hon. Members would do the same thing in their communities.

I should also mention that airlines would be a good partner for tackling deep vein thrombosis. As I am a Member of Parliament, I cannot help but create some self-publicity; the subject of my ten-minute Bill, to be debated on 25 January next year, is making airlines give more information on avoiding deep vein thrombosis during flights.

The message must be one of prevention, as well as cure. I understand the immediate pressures on the Department of Health. Great restructuring is taking place, and there are pressures to reduce waiting lists and tackle high-profile killers such as coronary heart disease and cancers. People are also clamouring for high-profile drugs and medical procedures, whatever the cost. There is a big challenge to deliver in Labour's second term and all those pressures crowd out more strategic thinking that will pay dividends later.

Mr. Edward O'Hara (in the Chair): Order. Those who organise the sound system are finding it difficult to catch some of the speeches, so I make a plea for speakers to address the microphones.

Mr. Kidney : I will back up a bit, Mr. O'Hara. The point is to have a strategic vision and a long-term plan. I believe that a long-term plan pays and reduces pressures

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later. An example of that from the past is intermediate care; we now face the difficulty of rushing to keep up with demand, which we should have planned for 10 years ago.

I want to answer the point raised by the hon. Member for Southend, West (Mr. Amess) about the nanny state because it is vital that we avoid being accused of attempting to develop one. I agree with the quote from the World Health Organisation that health promotion is

We must provide facts on healthy living through guidance that must become familiar to everyone. One shocking statistic from the report of the CCPR is that only 11 per cent. of GPs recognise the Government's guidelines on the amount of physical activity recommended for adults. If front-line services have not got the message, there is not much hope for the rest of the community.

11.34 pm

Dr. Richard Taylor (Wyre Forest): I should like to consider the role of the public health doctor, historically and now. I will show that I think that the role has somehow lost its way. As the hon. Member for Wakefield (Mr. Hinchliffe) said, it began with Sir Edward Chadwick, who was not a doctor but a Lancashire man brought up in a Lancashire farmhouse, in which the proverb, "Cleanliness is next to godliness", was the absolute rule. This proverb enabled him to live to the age of 90. During a long and profitable life, he sorted out the water system and proved the connection between water and illness.

Coming a little bit more up to date, in the 1880s, in my own constituency, we had a remarkably forward-looking medical officer of health, who, once he had established the waterworks, the sewers and the fire service—with which he was involved as well—he suddenly realised that the death rate from drowning in the River Severn was extraordinarily high. As the voice of the people he recommended that swimming lessons should be available. He then realised that a lot of the people who were drowning were drunkards who were just falling into the docks—in Stourport we have docks. The health officer then tried to get fences erected. He was not very successful with that, but he was amazingly forward-looking. The health officer also discovered that the mercury in teething powders caused desperate illnesses in children. This was not recognised until the 1950s; he was 70 years ahead of his time.

At that time medical officers of health really spoke for their people. Sadly, the medical officer of health role was abolished in 1974 and society then went into a limbo in which we had community medicine specialists. The community chest of the Monopoly board meant more to me than community medicine as a specialty. This was only put right by the Acheson report in 1988, which defined public health very sensibly as the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. Sadly, I think that that has been rather watered down in the report.

The Select Committee—of which I was not a member at the time—picked up the Association of Directors of Public Health description of the core business of the

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director of public health as being medical management with the science of epidemiology. That is where I think things began to go wrong. As a medical manager, the director of public health was automatically on the executive of various NHS bodies. As with other executives, they also became, in effect, civil servants. This produced a tremendous conflict. It has been referred to in at least one letter to the British Medical Journal from a very senior public health doctor, who pointed out how difficult it was to act as the voice of the patient when one was in fact a civil servant.

The loss of the director of public health as a voice of the patient has led to so many of the problems in my own constituency. The Independent picked this up relatively soon after my election to this House, and regarded the lesson of my election as a condemnation of the state planning of health services in the area, which had failed. The newspaper went on to say that, in the market,

Sadly, we did not have such a person to speak for the people. Those involved can convince themselves, through various methods, that what they are being told—they are, sadly, almost being dictated to—is in the best of interests of the people.

This role as a voice for the people is becoming more important. Only yesterday the press contained reports from the president of the Royal College of Surgeons, saying that because of the tremendous shortage of surgeons, a large number of hospitals would probably lose their surgical facilities. Unless we have a medically qualified voice of the people to speak up against the royal colleges, we will again be in trouble.

The role of the director of public health—the public health doctor—should be to get back to being the voice of the people. This gives me a little bit of hope because, with the reorganisation, the strategic health authority will have one senior public health doctor and—I hate to say this—he may be a long way away from being able to do much damage. I am not clear where the public health presence fits in with the primary care trusts and I should be grateful for more details of that. The Government stated in their response that there would be a new public health team in each PCT, with a board-level appointment to lead the work. I should like to have a little more detail about that and how it is envisaged.

I must mention sport, because it was one of the key points to which Liam Donaldson referred when summarising public health. They were; do not smoke, eat a balanced diet, keep active, manage stress, moderate alcohol, cover up in the sun, have safer sex, keep cancer screening appointments, read the highway code, and learn first aid. Several hon. Members referred to keeping active and that was emphasised at an inspiring meeting that a number of us attended yesterday with the Prince of Wales when we heard about his trust and charitable activities. In response to a question from the hon. Member for Leigh (Andy Burnham), the Prince acknowledged the importance of activity, including football. Another huge value of sport in the community, in addition to its tremendous health implications, is that it takes young people off the streets. I should like to hear a little more about the future role of the public health doctor and to have an assurance that sport and exercise will be emphasised.

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3.41 pm

Gareth R. Thomas (Harrow, West): I congratulate my hon. Friend the Member for Wakefield (Mr. Hinchliffe) on another excellent report from his Committee. I strongly endorse his comments on the need for a ban on tobacco advertising and I share his view of the importance of sport.

3.42 pm

Sitting suspended for a Division in the House.

3.57 pm

On resuming—

Mr. Thomas : The two issues that I want to highlight relate to anorexia and alcohol misuse. I apologise to the Minister and to other hon. Members for the fact that I shall not be able to stay until the end of the debate, but I shall read Hansard carefully tomorrow.

I urge a greater focus from the Health Development Agency and public health professionals on the issue of anorexia. I confess that I did not take a great deal of interest in the issue until a local family visited my constituency surgery. Mrs. Porter told me about the experience of her two daughters and their treatment for anorexia. Their treatment illustrates both the best side of the national health service and a side on which further work is needed.

In 1996, Helen Porter received treatment as an in-patient at Bowden house, a facility in my constituency. She was there for some six months on a placement funded by the national health service. In the words of Mrs. Porter, her daughter made excellent progress. Sadly, Rachael, her second daughter, also suffered from anorexia and became ill in 1997. Unlike her sister, she received much more sporadic treatment for the same condition. She managed to continue at university and graduated successfully last year, to the delight of all her family. When she came home from university she was, in the words of her mother, "at death's door," weighing some 30 kg. Thirteen months on, when her mother came to see me at my surgery in July, Rachael weighed only 3 kg more. She has not had the opportunity to receive the same high-class treatment at the Bowden house facility in my constituency as her sister did.

When I started to consider anorexia, I was surprised—perhaps I should not have been—to learn how widespread the condition was. An estimated 60,000 people in the United Kingdom have eating disorders. I am told that only one in 10 sufferers are male, and the majority are young women. The problem affects roughly 1 or 2 per cent. of the UK's female population between the ages of 15 and 30. Of the statistics, the most frightening must be that between six and 10 out of every 100 patients die as a result of the disorder.

I did further research and read with great interest "Eating Disorders, Body Image and the Media", the report of the board of science and education of the British Medical Association, which was published in May 2000. The report highlighted a range of issues of

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importance for public health professionals and stressed the importance of education, which might relate to the point made by my hon. Friend the Member for Wakefield about the importance of the role of local authorities in improving public health. It also identified the need for clear anti-bullying policies, proper policies on eating disorders at a local education authority and school level, and proper counselling and mentoring services. The report advocated greater research so that some of the underlying causes of anorexia could be identified, as there is still no clear view of its cause. It made a series of recommendations on diet, physical activity and mental health services for the Government's health strategy.

The Government are acting on the issue. The Minister for Public Health rightly called a summit in June 2000 to stimulate debate on the issue. I urge the Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), who is in the Chamber, to consider urgently what else the Government could do to respond to the concerns of organisations such as the Eating Disorders Association. The association has highlighted the difficulty of access in some areas to specialist eating disorder treatment, the difficulties in recognising eating disorders as a problem in primary care, and differences in patterns of referral among general practitioners and other primary care professionals. The EDA has also advocated the development of therapeutic options for the problem, which are not as advanced as those for better known and more high-profile conditions.

I suspect that another point made by the EDA was referred to by my hon. Friend the Member for Wakefield in the report of the Health Committee on mental health services. It stressed that treatment for those who suffer from eating disorders must take place in appropriate settings. It is sad that settings are less than ideal at the moment.

For the sake of my constituents, I look to the Minister and her colleagues in the Department of Health to continue to seek to raise the profile of the issue and the Government's response to it. That family has gone through considerable trauma as a result of the condition.

I urge the Government to consider alcohol misuse, a subject that other hon. Members have mentioned. I have spent time on the scheme run by the National Council of Voluntary Organisations—which is equivalent to that run by the Industry and Parliament Trust—with Alcohol Concern, an excellent organisation that rightly continues to campaign for an alcohol misuse strategy. It has consistently highlighted the importance of alcohol to a wide range of social, economic and health problems. There is a huge public health dimension to alcohol misuse. The number of deaths directly attributable to alcohol misuse rose sharply in the second half of the 1990s from some 3,800 per year in 1994 to over 5,500 in 1999, while 60 per cent. of employers stated that their organisations had experienced problems as a result of employees' misuse of alcohol. I am told that a comparative study has shown that 15 to 16 year-olds in the United Kingdom have some of the highest drinking levels in Europe.

There is also a clear correlation between alcohol misuse and crime, notably in terms of domestic violence—60 to 70 per cent. of men who assault their

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partners do so under the influence of alcohol. Most tellingly, as others have mentioned, at peak times 80 per cent. of those who go to accident and emergency departments with injuries have a high percentage of alcohol in their bloodstream.

A Government strategy to tackle the problem could create coherence across the various Government Departments that have an interest in alcohol policy. Such a clear political commitment would have an enormous impact on a range of providers of services, and the imposition of clear targets would lend urgency to the tackling of problems. A strategy could also identify the structures in the public health domain and elsewhere that might be able to help to address the issues. I urge the Government to direct additional funding to this aspect of public health. I understand from a written answer to the hon. Member for Twickenham (Dr. Cable) that just £1.1 million has been allocated specifically to deal with alcohol misuse as opposed to £91 million to tackle drugs and almost £34 million for tobacco. I do not condemn the Government for that, but I urge that, as part of a proper national alcohol strategy, another look be taken at funding in this important area.

I apologise again that I cannot be present to hear what my hon. Friend the Minister says. However, I shall study her response, and the contributions of other speakers, very closely.

4.7 pm

Mr. David Tredinnick (Bosworth): This is a timely and important debate. I congratulate the hon. Member for Wakefield (Mr. Hinchliffe) and his Committee on the vast amount of work that they must have put into the report and their travels to other places. It is important to have this debate now because, I suggest to the Minister, the Government have entertained us with some dramatic changes in health policy in the last week or so. I do not expect my hon. Friend the Member for North-East Hertfordshire (Mr. Heald) to agree that the Government have pirated Conservative policy in trying to get the private sector involved in the health service in the way for which—I see my hon. Friend smiling—we have argued in at least the past two Parliaments.

Mr. Heald : Just to take up my hon. Friend's partisan note, does he agree that it is sad that, for five years, so many patients have suffered when they could have had their treatment through the private sector?

Mr. Tredinnick : I hear what my hon. Friend has said. I agree with him. It is not my intention to have a party political knockabout.

Mr. Hinchliffe : I understand from a colleague that last week the Public Accounts Committee calculated that the NHS would have the equivalent of 2,000 additional consultants if those who worked part-time in the NHS and part-time in the private sector worked wholly in the NHS. I am not completely on board as regards the Government's current direction. If they moved in the opposite direction, they could have a profound impact on our problems with waiting lists.

Mr. Tredinnick : I was going to suggest that there was an inconsistency in the Government's policy. On one

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hand, they want the private sector to deal with acute cases; on the other, the Minister and her colleagues have not dealt with complementary and alternative medicine, which is largely in the private sector. I shall return to that.

Dr. Evan Harris : The hon. Gentleman suggested that a Government addiction to the private sector was a panacea for which he had called for some time. However, that does not mean that he was right, because both the Conservative party and the Government could be wrong.

Mr. Tredinnick : I have never looked to the Liberals for panaceas, and I never will.

Dr. Harris : Liberal Democrats.

Mr. Tredinnick : I am sorry; the Liberal Democrats. We have had the Social Democrats and—perhaps I should not go down that road, because I would hate to be called to order.

The second aspect of the Government's change of policy is that they have pretty much admitted that they cannot solve the problems with the existing criteria. The evidence for that is that they have had to go to the Chancellor for more money. I have never agreed with the Chancellor on much, but I certainly agree that he should audit what is happening at the Department of Health. The Treasury is always very tough when it is asked for more money, and I welcome that.

The third dramatic change is the decision to send patients abroad for treatment. I welcome the idea that we should reduce waiting lists, particularly if that benefits those of my constituents who are on them. However, as I have said before and I shall say again, the Government should look to those who practise different forms of therapy in this country but who are not properly integrated into the national health service. If the Government drew on the resources of those 50,000 additional practitioners—the hon. Member for Oxford, West and Abingdon (Dr. Harris) smiles in what I hope is agreement—the numbers on waiting lists would fall and life would be much easier for doctors and surgeons.

When I read the report yesterday evening, I was slightly amused that the Committee had alighted on Cuba as its destination. I wondered whether we were dealing with new Labour or real Labour, the Stalinist tendency. I wondered whether the right hon. Member for North-West Durham (Ms Armstrong) was behind the report. She has a tendency to get involved, as she did in the case of that poor Labour Member who was hounded by the Labour Whips. The press release said, "Labour thugs attack MP"—

Mr. Edward O'Hara (in the Chair): Order. The hon. Gentleman is departing from the script.

Mr. Tredinnick : I certainly would not want to do that, Mr. O'Hara. However, it crossed my mind that those were the right people to go to Cuba to get a few lessons and perhaps some beer, sandwiches and cigars from

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Fidel. I am sure, however, that the hon. Member for Wakefield is not part of that militant tendency in the Whips Office.

Mr. Hinchliffe : I do not know whether the hon. Gentleman has been to Cuba, but its people are probably the nicest that I have met in any of the places that I have visited.

Mr. Tredinnick : I have not been to Cuba, but I look forward to an invitation. I am unlikely to get one from the President after my remarks, although I live in hope.

I was interested by paragraph 19 on page 15, which stated that life expectancy in Cuba was 76 years. Paragraph 21 on page 16 states:

in Cuba—

[Interruption.] I thank hon. Members. Turning to paragraph 29, hon. Members will see that life expectancy in England and Wales has increased from 52 years and 55 years for women in 1910 to 74 years for men and 79 years for women in 1994. Our life expectancy here is still worse than that in Cuba. One reason for that is that the alternative and complementary services that are available in Cuba are not available on the national health service in Britain.

Mr. Hinchliffe : And we do not have socialism, either.

Mr. Tredinnick : The hon. Gentleman, as ever, makes a point that, coming from his stable, he might be expected to make. It seems bizarre that citizens of a country that cannot afford pharmaceutical products—another paragraph says that it is not allowed to import them because of the cost—and uses natural remedies have a better life expectancy than the citizens of a country that can afford pharmaceutical products. I respectfully suggest that there are one or two lessons for us there.

Dr. Harris : The hon. Gentleman is raising a very important, very serious matter. However, does he accept that better lifestyles and prevention, rather than treatments, whether conventional or alternative, are what count in terms of life expectancy? If a place has those better lifestyles, the use of the herbal and alternative remedies there does not prove that those remedies have a positive effect on life expectancy; rather it proves, and I think that many people would agree, that lifestyle issues have an impact.

Mr. Tredinnick : I do not often agree with the hon. Gentleman, but I will agree with him a little this afternoon. I accept that lifestyle is an issue and I intended to talk about that and about the amount of money that we spend on preventive care. Sport is important in Cuba, and people's lifestyle is more relaxed. I do not know whether my hon. Friend the Member for Southend, West (Mr. Amess) had a pina colada on a beach—perhaps he did. Cuba is a big tourist

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destination, is it not? My hon. Friend is such an assiduous worker—I well remember his efforts at Basildon in the old days.

I hope that no one in the Chamber thinks that I am being flippant. Although I am trying to lighten some aspects of what I say, these are key issues. I read the report unable to believe my eyes that the Cubans should be using alternative therapies and have a greater life expectancy. In this country, already one in four people are using some form of traditional therapy, or "integrated health care" as we tend to call it now. Such therapies include herbal medicine, acupuncture, back treatments such as shiatsu, reiki—all sorts of things. There are roughly 750,000 consultations a year with 50,000 complementary practitioners. Most referrals are outside the health service. Some are now inside—we are just beginning to get there.

The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears ) indicated assent.

Mr. Tredinnick : The Minister nods and it is true, but there is a long way to go. The Government could make their life so much easier if they moved forward on the issue.

The House of Lords Select Committee on Science and Technology, in its landmark report, came to the conclusion that complementary therapy—the herbalists and homeopaths—had been adversely affected by the recent NHS reforms in primary care. Primary care groups have brought about a levelling down in services, and 58 per cent. of primary care groups now provide access to some form of complementary therapy. A recent survey of primary care groups found that 227 out of 278 had not come up with a policy on the matter.

The difference between GP fundholding and the primary care group system is that whereas, in the past, GP fundholders could get together as a small band and commission, primary care groups tend to be more unwieldy because more people are involved. Crucially, their membership includes quite a few old-style health authority officials. It is often less easy to commission therapies on the health service. The Minister would be well advised to examine that so that we get an increased provision in the health service, which is important when regulation is gradually being improved for all therapies.

I served on the Committees of the Osteopaths Bill and the Chiropractors Bill three Parliaments ago; those provisions are now part of mainstream health care. In those days, such treatments were considered pretty wacky. When I damaged my back many years ago, I would certainly not have told a doctor such as the hon. Member for Oxford, West and Abingdon that I was going to an osteopath, because he would have been tough with me and told me that he thoroughly disapproved.

John Austin : Does the hon. Gentleman agree that if chiropractic was more readily available under the national health service, the waiting lists for orthopaedic surgery would be dramatically reduced?

Mr. Tredinnick : That is absolutely right. One of the hon. Gentleman's hon. Friends, whose name I shall not mention because he is a good friend of mine, told me

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that he went to visit a chiropractor in a major city in England. When he was waiting for treatment, he was surprised to bump into an acquaintance. He said, "Hello, what are you doing here—you're the chairman of the local health authority, why aren't you at the royal infirmary getting treatment for your back?" His acquaintance said, "I'm not letting those people near me; I'm coming here first."

That story should not suggest that there was anything wrong with the surgeons in the hospital, but I agree with what the hon. Gentleman says—I nearly called him my hon. Friend, but I would not want to damage his chances of promotion. If one allows chiropractors in first to examine backs, pressure is taken off the waiting lists for the surgeons, who can concentrate on valuable and necessary work. The complementary world can take the pressure off the health service.

The Government have outlined targets—national health service priorities—among which coronary heart disease, cancer and mental health are key. I can remember them without looking them up. I was talking to a homeopath yesterday and he agreed that all those priorities could be dealt with using homeopathy. Hypertension, which leads to heart disease, is readily curable using homeopathic medicine, as are ulcers and asthma. My hon. Friend the Member for Southend, West mentioned asthma, of which he has family experience. My children have had experience of asthma, and it is frightening when it happens, but there are remedies.

Remedies for skin may also be effective, and the treatment does not have to involve powerful steroids with their side effects. I do not suggest that there is anything wrong with traditional approaches, but there are other ways in which to treat those health problems before using powerful drugs. Let the doctors use them, but let us try other remedies first and take the burden off the health service.

I shall concentrate on homeopathy for a moment, before turning to some other therapies. In Scotland, 20 per cent. of doctors use homeopathy—one in five. One of the reasons for the Act of Union with Scotland was to get doctors down to London, was it not? I think that happened in 1706—I am not an historian. We have always had a great respect for Scots medicine. We do not have anything like that here—we have only five homeopathic hospitals. We should build on that, and the Government have an opportunity to take the initiative.

Regrettably, doctors sometimes like to say that homeopathy is all rubbish and that nothing has been proved, but studies on complementary medicine are often ignored. The study entitled "Unexpected solute aggregation in water on dilution" was received in Cambridge on 20 June and accepted on 7 September, which means that it was accepted by the medical establishment. Homeopathy works through weak doses: the weaker the dose the more powerful it is—so it is more powerful if it is diluted from 30c down to 6c or 1m, for example. That has been scientifically proved. It is an important study and we must take note of it.

Yesterday I was with someone who has been using homeopathy to treat dysfunctional children—the type of children whom we were talking about earlier in the debate—at Impington village college in Cambridge. I

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have been given leave by the college, via the therapist, to draw the matter to hon. Members' attention this afternoon. Impington college asked homeopath Jacqueline Schaerer to help with its inclusion project. The trial proved successful.

A group of 25 children from 12 to 15 years old, with behavioural problems such as violence, swearing, truancy, fighting in the classroom, shoplifting and being generally disruptive in and out of school were treated individually, and sometimes in groups, with homeopathic remedies either weekly or monthly, with the parents' consent. After the relatively short time of three months, the teachers reported that the majority of the treated students were back in a normal classroom situation, behaving acceptably and studying to the best of their ability. Impressed by the results, the college decided to support some of the 16 to 18-year-old students; they had more emotional social problems, including suicide attempts, eating problems and even drug taking, which disrupted their education and their exams. The results were equally successful.

Impington village college valued the input of the homeopath as an important strand of its educational inclusion work. Now, a year later, the same students are still behaving in an acceptable manner but without any kind of further treatment. That is significant. I understand that almost all the pupils who received that treatment have effectively been cured of their problem. Not only have the pupils benefited; so have the teachers, parents and society in general. The trial was considered a huge success. The inclusion project was funded by Government grant No. 19.

Homeopathy can result in enormous savings not only in the general health sector, as I have suggested, but in education. The Minister seems very interested in that. If she wants to see them, I shall ensure that she has a copy of the papers. The Homeopathic Society has 1,200 members, and they are all available. The Minister can lock them onto the health service. Homeopathy has been available on the health service since 1950; she does not need to look at the regulations, and there is no reason why that should be a stalling point.

When the House of Lords reported on the subject last year, there was absolute uproar among the Indian community here and in India at the fact that ayurvedic medicine was not classified as a serious therapy. I looked up some statistics for the debate, and ayurvedic medicine has been used for more than 6,000 years and is practised in 2,000 Indian hospitals. Yet we have the audacity to say that the treatment is not proven. We need a radical rethink on our attitude to medicines from Asia, because they are increasingly popular and they have a formidable ability to cure problems.

I have in my hand a list from a Chinese practitioner who lectures in Chinese medicine and who trains western doctors in London in how to use it. The list shows the problems that traditional Chinese medicine can cure using acupuncture, which is part of traditional Chinese medicine. I shall give a copy to the hon. Lady—I nearly said right hon. Lady, but not quite: if the Minister adopts and embraces complementary medicine, she might soon be promoted and might yet be asked to the Palace. The document lists the therapeutic functions of acupuncture. They include analgesic and anaesthetic functions. Acupuncture deals with nervous problems, regulates body fluids, regulates the digestion,

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helps with respiratory problems and deals with the circulation, blood pressure, cervical vessels, coronary artery and digestive system. It can affect the blood, and is used in red cell and white cell management; it deals with blood platelets, and has an effect on the endocrine system, the nervous system and the immune system. I could go on.

Dr. Richard Taylor : I am sure that the hon. Gentleman is aware of the Prince of Wales Foundation for Integrated Medicine. Its aim is

That organisation is trying to set up controlled trials of complementary forms of treatment, and I commend to the hon. Gentleman that method of furthering his desires. I also commend to the Minister the work of that organisation.

Mr. Edward O'Hara (in the Chair): Order. Before I call the hon. Member for Bosworth (Mr. Tredinnick) to continue his speech, I want to advise hon. Members that the winding-up speeches will start at 5 o'clock, and the intention is that each of the Front-Bench spokesmen will have 10 minutes each. Hon. Members who still wish to speak—I know that two are still hoping to catch my eye—might like to bear that in mind. Should we finish before 5 o'clock, the extra time will be allocated between the Front-Bench spokesmen, and should we be interrupted by Divisions, we may have extra time.

Mr. Heald : On a point of order, Mr. O'Hara. We have already lost 12 minutes or so as a result of a Division. Will we have extra time to make up for that?

Mr. Edward O'Hara (in the Chair): We have until 5.45 pm, but if there are further Divisions we may add some time. The winding-up speeches will start at 5.15 pm.

Mr. Tredinnick : On a point of order, Mr. O'Hara. It might assist if I inform you that I spoke to the Table Office on that very point. I was informed that we have extra time for every Division.

Mr. Edward O'Hara (in the Chair): That is right. I have just said that.

Mr. Tredinnick : I am sorry; I misunderstood you.

Mr. Edward O'Hara (in the Chair): I shall not repeat myself. I think that people understand. We should not waste any more time.

Mr. Tredinnick : I hope not to waste any time and I certainly have no intention of talking out colleagues who want to make a speech. I shall try to speed up.

There is currently a big debate about the regulation of acupuncture. The Minister can help by taking that forward and ensuring that herbalists and acupuncturists

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are regulated. Then more doctors will refer patients to them, as happened when osteopaths and chiropractors were regulated.

I turn briefly to the issue of obesity, which has been raised by several hon. Members. I agree that it is a terrible problem and an indictment of our society, and that we must do something about it. The statistics in the report show that physical education has been reduced in a third of primary schools, there is no physical education at all in 95 per cent. of primary schools, and children spend twice as much time watching television or playing with computers as doing sport. It is vital that we redress that state of affairs. Whether the Department for Culture, Media and Sport is the right vehicle for that is an important issue.

In Australia and Cuba, sport is seen as part of health. I try to exercise every day. I go to a yoga class on Wednesdays, if the Whips are kind to me and I can get away. I find that beneficial because it gets the blood moving. On the subject of smoking cessation, I defy anyone to try smoking a cigarette after a yoga session. I speak as someone who has just about knocked the habit on the head. The money that the Government have made available for smoking cessation services is very important, as I told the Minister at Health questions. Hypnotists and homeopaths can help too, and acupuncture is effective for smoking cessation, so I hope that the Government will examine those possibilities.

On diet, there is a problem with additives. A study in a secondary school, published a week or so ago, reported on the problems of E-additives in orange juice that can cause disruptive behaviour. There is too much sugar in our diet.

I have always believed that there are three classes of medicine: mainstream, conventional medicine; herbalists and homeopaths, whom I would loosely describe as "alternative"; and energy people and healers who use their hands and work with energy medicines such as Bach flower remedies. People who heal with their hands work in advanced cancer clinics such as those in Hammersmith and Bristol. Prisoners are being shown how to channel energies in prisons such as Coldingley near Guildford and Hollesley Bay near Ipswich. I have watched remarkable demonstrations in which prisoners have worked with warders and warders have worked with prisoners.

During birth, babies can have their cranial plates put in the wrong place as they go down the birth canal, and cranial osteopathy can help with that. Many prisoners have plates that are out of place, and a cranial osteopath can put back those plates, which can completely change their behaviour patterns.

Only 2 per cent. of Britain's health care budget is spent on prevention. We must look harder at prevention, and we should certainly look harder at sport.

According to the Library's statistics, the amount of research funding for complementary and alternative medicine is 0.08 per cent. of Department of Health and Medical Research Council funding, and 0.05 per cent. of research funding from medical research charities. It is a pitiful sum when one considers the money that the drug companies attract.

The report is tremendous and a great deal of work has gone into it. We can learn one or two interesting lessons from Cuba, but the big lesson for the Government to

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learn as they send patients across the channel before they go to the Chancellor with their begging bowl is that they should make better use of the indigenous complementary practitioner population.

4.36 pm

Mr. Barry Gardiner (Brent, North): I am delighted to follow the hon. Member for Bosworth (Mr. Tredinnick), who has spoken extensively. Indeed, he has spoken for longer than the Chair of the Committee, my hon. Friend the Member for Wakefield (Mr. Hinchliffe) did. The only thing about which he has not informed hon. Members—perhaps he will enlighten us—is whether there is a homeopathic cure for verbal diarrhoea.

It is a great pleasure to speak about the Health Committee report because it is excellent and raises several important issues. My interest in public health dates back to the days when my mother was the medical officer for the west of Scotland. My childhood was spent being carted around various developmental clinics that she had set up, so I speak with the benefit of years of experience of public health, albeit not of the professional variety.

The report highlights the issue of health inequalities. The Chair of the Committee said that health inequality had doubled or tripled in the past decade—he would want me to make it clear that over that period, life expectancy and health increased dramatically while morbidity decreased. None the less, health inequality concerns all hon. Members, including Ministers.

I want to speak specifically about the section of the report that states:

Given that my constituency is located in a borough where 106 languages are spoken in schools, health inequality among ethnic minority groups has troubled me for a long time.

I should like to focus the Minister's attention on the problems that such groups face in screening programmes—specifically, breast screening programmes. I believe that the problem is that the system is based on the convenience of doctors and the administration. It seldom takes account of the culture and traditions of Indian and other Asian communities. I am delighted to say that, about a year ago, my hon. Friend the Minister for Public Health visited my constituency to examine the breast screening programme there and speak with the Indian and Asian community about cultural differences.

At present, when the letter from the doctor arrives saying that it is time for a woman to present herself for screening, in most households of those communities, if the woman opens the letter, she will go to her husband and say, "I have this letter." If the husband does not say at that point, "That's good, it is important for the family that you go and do this," the letter goes in the bin. It is absolutely vital, especially in areas where many women, particularly elderly ones, do not speak English as their first language or even at all, that there is support from the family network and from the wider community to

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ensure that the women not only go for screening, but are supported when they go by another family member who speaks English.

One would imagine that mobile units were a way of addressing that problem but, sadly, they are not as mobile as their name implies. They often get dumped in a Sainsbury's car park for six months, nine months or a year at a time and people are referred to them. I urge the Minister, with her ministerial team, to examine working with local community groups such as, in my constituency, the Brent Indian Association and the Hindu Council of Brent, to make it clear that the work starts with them. The mobile unit could be located in a venue such as the local community association, and the whole community would then be encouraged to ensure that people present for screening.

We could then invert the process whereby the reference comes down centrally through the doctor to the woman, and the matter then goes into limbo. It must come from the community so that the support is there to ensure that women present for screening and receive the care that they deserve. We must turn the focus of the service delivery on its head and try to make it customer-focused and patient-focused, instead of designed for the doctors' convenience.

Dr. Evan Harris : I am very interested in the cogent case that the hon. Gentleman is making, but could he be more specific? How can those letters of invitation, an important part of the screening process, come from the community, given that they contain confidential medical information?

Mr. Gardiner : I am saying not that the letters of referral should come from the community, but that if one located a mobile unit at a community venue and a campaign was then undertaken with the local community association—a particular ethnic or community group—women would be encouraged to present for screening. The work would then be done in a venue with which the women were familiar and with the support of the whole community. The point has been made by the men who are leaders of their communities that unless the men in each family give support, the letter will not be acted on. It is vital that we seek to turn the system round, and ensure that the inequalities in health care that the report so properly mentions are tackled in ethnic minority communities.

My hon. Friend the Member for Wakefield was right in his remarks about the importance of health visiting. Health visitors have a vital role to play in health promotion and the delivery of primary health care. My hon. Friend's remarks are indeed timely, given that the draft Nursing and Midwifery Order 2001—a reference to health visitors used to be included—is being debated this week in another place.

At a recent meeting, the Minister of State, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), referred to health visitors as his shock troops for the delivery of primary health care and preventive medicine in the community, and for looking at how best to overcome social inequality. The report highlights Sir Donald Acheson's remarks about the

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uncontroversial benefits of home visits to pregnant women and during the first two years of a child's life. Health visiting is an absolutely vital front-line support for mothers and young families. It is central to what this Government are trying to do through the sure start programme and other measures. It ensures equality of health opportunity for young children from the outset, no matter what part of society they are born into.

The report makes an important recommendation about how health visitors can get involved at the other end of the life cycle. It looks at the ways in which health visitors can use and develop their skills in order to present an equal service to the elderly population. The recommendation fits in with the Government's agenda to extend skills traditionally concentrated in health visiting and health visitors, so that the role of community public health practitioners is enlarged.

In passing, I should mention the draft Nursing and Midwifery Order 2001, and the health visiting profession's concerns about it. The profession has been surprised—I put it no more strongly—to find that the name of "health visitor" has been omitted from the order, and that it will be registered not as a distinct profession, but as a distinct nursing specialism. Given the shock waves that that decision has sent through the health visiting profession, it is vital that Ministers send the strongest possible signal that they value the role of health visitors in our primary health care delivery programme, and that they will protect in statute the body of knowledge that health visiting has built up over decades. We have been told that the education, skills and training of health visitors will be protected in statute, and Ministers must offer that assurance.

The other day, I had the good fortune to launch my own local strategic partnership, in Brent. The report is excellent in highlighting the role that such partnerships should play in building alliances across the community by working with elected bodies, the local council and all manner of authorities. Paragraph 149 of the report states that

That is an extremely important part of the report's argument, and I commend the Committee for its work in highlighting that point. I hope that the Government will take that forward.

The section of the report beginning at paragraph 178 concerns cross-Government work on school health. It says:

Many important points are contained in that short passage and, indeed, in the report's other comments on the subject.

I welcome the Government's programme for making fruit available in schools. My local area was one of those in which it was piloted. It is a tremendous initiative, and I look forward to its roll-out across the country. It is

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vital that children be educated into good nutritional habits and that they get the benefit that the fruit in schools programme has delivered to schools in my constituency.

I want to pay far more critical attention to the Government's policy on physical activity by children at school. The expectation that schoolchildren should have two hours per week of physical education shows a poverty of aspiration on the part of the Government that is shameful and shocking. It is a disgrace, especially as the time that children are given has declined since 1994, when they were getting two hours a week. They should have two hours per day, not per week. In respect of cross-departmental co-operation, I am delighted that the Minister for Sport is working with Ministers from the Department of Health, but we must recognise that unless policies are implemented with the full and dramatic co-operation of the Department for Education and Skills, we shall not achieve the objectives that we set.

The Chairman of the Committee was right to highlight the report on obesity that went to the National Audit Office, and to the Public Accounts Committee on which I serve. The revelations in that report were shocking. Obesity is increasing faster in children than in any other age group. From 1984 to 1994 it rose from 5.6 per cent. to 9 per cent. in boys and from 9.3 per cent. to 13.5 per cent. in girls. In 1999, the direct costs to the nation of obesity reached £0.5 billion, and the indirect costs are estimated to be £2.5 billion. It is pointless to channel funding into treatments for the diseases that are caused by obesity, which is recognised as a so-called gateway disease to a host of other ailments, if we do nothing to address the root causes of obesity through good nutrition and exercise.

I shall draw my remarks to a close because I know that other hon. Members have important contributions to make. I plead with the Minister to ensure that her Department, the Department for Culture, Media and Sport and the Department for Education and Skills consider restructuring the school day. It should be put on the same footing as the working day, starting at 8.30 in the morning and finishing at 5.30 or 6 o'clock at night. In the middle of the day, at about 2 o'clock, two solid hours should be taken out for sport and physical activity—not after the school day has finished, as extra-curricular activity. That central position in the timetable would make sport central to the curriculum. Children would spend the same amount of time in the classroom as they currently do, and the period in the middle of the day could be well used by teachers for the preparation and marking of work that they now have to do after the school day. The Department for Culture, Media and Sport is already saying that it will put money into increasing the provision of coaching and development in that area.

Unless there is an integrated approach that looks to putting two hours of sport and physical activity at the heart of the school day, I believe that we shall not be able to deliver the health improvements that we seek for young people.

4.55 pm

Andy Burnham (Leigh): Public health is such an important subject, and it is great to have the opportunity to talk about it in such detail today. I pay

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tribute to the contributions that my hon. Friend the Member for Brent, North (Mr. Gardiner) and many other hon. Members have made today. It is sad that we do not have more opportunities to talk about the subject. Public health is one of those things that touches almost every facet of life. The work of every Government Department is crucial to the lives of people in this country, but I believe that we should give public health more attention.

The report on public health is fantastic, and it is a tribute to the Health Committee. Sadly, I can take no credit whatever, as I did not join the Committee until the summer. I am sadder still that I missed the intriguing trip to Cuba, although I am glad that I did not have the British Airways prawn butties, which, by the sound of things, are doing their own damage to the health of the nation.

I pay tribute to my hon. Friend the Member for Wakefield (Mr. Hinchliffe). It is obvious when he speaks on this subject that he does so with great passion, conviction and knowledge, and he deserves to be listened to. The report is a tribute to him, and also to the hon. Member for Southend, West (Mr. Amess) and my hon. Friend the Member for Erith and Thamesmead (John Austin). The report has shaped Government policy; we can say that with great certainty, and that alone is a great tribute.

My background in this area is that I worked for a short time for the NHS Confederation and helped to prepare its response to the Acheson inquiry in the late 1990s. While we were talking about the Acheson report we began to see how engrained and embedded the issues were in some of the more deprived communities of the country, but it was only recently, since I became the Member of Parliament for Leigh, that I began to appreciate some of those issues at first hand. Only then did it strike me how hard it was to get underneath the issues and tackle them without being glib about the subject.

As people will know, Leigh has a long and proud industrial past, and a great tradition in coal mining; but that has left a terrible legacy to the local population. I find it quite humbling when former miners visit my constituency surgeries to see their pallid skin and to see them struggling to get around. The industrial past of the town has left great scars on the local population's health. Nothing can be done now for that generation, but let us hope that we can give the younger generation something better later in life, when they reach the same years.

What I have learned locally on an anecdotal basis has been borne out by the report of the chief medical officer this week. Some of his findings are truly shocking—a national scandal. I shall read a few conclusions from his report. He said:

He is talking of the late 1990s, when the data were collected. He continued:

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A partisan note was injected into our debate by the hon. Member for Bosworth (Mr. Tredinnick), who seems to have left the Chamber. The conclusion that I have just quoted is an indictment of the policies pursued in the 1980s and 1990s by the Conservative Government.

The chief medical officer said that

He qualified that remark by saying that it was because

A few months ago there was a debate about whether the north-south divide still existed. This report gives anyone who cares to look at it absolute, concrete and conclusive proof that the north-south divide is, sadly, very real.

The findings of the chief medical officer are the product of the failure of successive Governments to get behind the issue. We can say only that they failed the people in the communities where problems are still bad. The chief medical officer drew particular attention to the 20 worst wards in the country. The Minister will know that, because some of the wards of her Salford constituency are highlighted in the report. She, too, feels passionately about the subject and will be committed to making a difference, as are we all.

The report shows that housing, leisure and lifestyle opportunities, job opportunities, personal fulfilment and schooling all shape people's lives and future health. From the standpoint of my constituency, I must say that the Government are acting to address those fundamentals. Last week we were awarded £58 million to improve housing in the Wigan borough, connected with the setting up of the arm's-length management organisation for housing. We also have, in Hindley, sure start, which my hon. Friend the Member for Brent, North mentioned. That is an attempt to get behind some of the difficult issues that have entrenched health inequalities in our population.

It is ironic that a Government often accused of being headline-grabbing and after the quick soundbite are putting in place policies that will deliver only 20, 30 or 40 years hence. It is a tribute to the people and the Government who have pushed those policies through that they have not gone for easier policies that produce results quicker.

I am extremely encouraged by the reforms to the national health service currently under debate in this place. Primary care trusts will have a powerful role to play in tackling health inequalities. They offer a more finely tuned mechanism to get behind the problem of health inequalities. They will be able to be more sensitive to local health needs and, crucially, less hidebound by traditional health service orthodoxies over prescribing, health promotion and other initiatives related to increasing the activity of the local community. The health service has, to date, failed on those subjects. It has not been as focused on public health and health promotion as it should have been. We now have an opportunity to turn that round.

The Government are currently examining the funding formula for primary care trusts. I hope that the Minister will touch on that when she replies. When that formula is drawn up, I hope that the Government will examine

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closely the chief medical officer's report and the stark health inequalities that still exist in this country. As the chief medical officer says, this is not just about resources, although those are extremely important. Areas where death rates are unacceptably high need resources to begin to tackle the health problems in their communities.

We must look at the issues more broadly. Will the Minister urge her colleagues in the Government to recognise the importance of the funding of local authorities in the tackling of health inequalities? As the chief medical officer points out, the whole range of facilities, services and opportunities for people touch on their future health. Those are provided by local authorities, and the funding that they have reflects their ability to provide high-quality opportunities to the local population.

It follows naturally that funding for deprived areas such as mine in the Wigan borough must be increased if improvements are to be made. As the Member of Parliament representing Leigh in that borough, I certainly want to see those improvements.

I would like to emphasise a point that, encouragingly, all hon. Members have touched on today—the need to promote sport in society. I am surprised that all hon. Members touched on that, because it is sometimes seen as a peripheral or add-on subject to public health. It is not; it is absolutely at the heart of public health. It has a crucial role to play in driving up the quality of life. It makes people feel better about themselves, puts them in a more constructive frame of mind and gives them opportunities and life chances that they did not have before. It helps people out of a negative cycle and into a positive frame of mind, which has knock-on effects on health.

My hon. Friend the Member for Wakefield mentioned the National Audit Office report, which contained figures for obesity in children. That alone should be enough to show that we are not doing enough to get young people to take part in sport. I believe that sport holds the answer to many of the entrenched and intractable social problems that the Government face—not just poor health but antisocial behaviour. In my constituency, there are often gangs of teenage children hanging around street corners of an evening, rattling the letter boxes of old people's houses and, worse, letting off fireworks and the like. Places could be provided for them where sports facilities were available, such as a floodlit astroturf pitch. Schemes around the country—I think that they are called midnight leagues—are targeted at areas with high crime rates. They provide attractive environments for young people—they are seen as a bit daring and trendy—and draw people away from less antisocial behaviour.

Sport tackles exclusion and improves regeneration. A town such as Leigh does not always have a great deal going for it, but people are united by a passion for sport—in our case, for rugby league. The hon. Member for Wakefield may agree that supporting rugby league clubs, such as those in Leigh and Wakefield, can sometimes be bad for our health and that of the local population. However, it is a passion that runs deep. Sport can be a galvanising factor in turning

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communities around; it gives them something to be proud of and draws them into healthier and more constructive lifestyles.

I should like to read a letter that I received from a 12-year-old constituent called Katie Parkinson. She wrote to me after I had written an article in our local paper. She said:

That says it all. My hon. Friend the Member for Brent, North mentioned the drastic rise in obesity. The reason for that is that places to play supervised sports in out-of-school hours do not exist.

The hon. Member for Southend, West said that part of the problem was that sport was regarded as the poor relation in Whitehall—indeed, it is seen as barely worth considering. I speak as someone who has worked as a special adviser in the Department for Culture, Media and Sport. We have worked extremely hard there for more funding for sport and it irritates me when the media comment on things such as Wembley. I take some credit for the fact that we persuaded the Government to make £750 million available through the lottery for the sport in schools initiative, which targets sports facilities in schools that are open to the community during out-of-school hours. We also managed to double the Treasury budget for sport, which, as the hon. Member for Southend, West said, will go into coaching initiatives. That is crucial. Organisations such as Sport England and the Central Council for Physical Recreation have done excellent work and have shown how we are still failing to fund sport adequately in this country. Trevor Brooking, the chair of Sport England is a great champion of that issue.

As regards solutions, one simple fact remains. The provision of sport and leisure facilities is not a statutory duty of local authorities. In the leisure sector, they are required by statute only to provide a full and comprehensive library service. Given the financial climate in which local authorities work, sport is often the first to go. We have all seen that in our constituencies. When times are hard, the grass is not cut, the person who supervises the facilities disappears, and the graffiti appears. That starts a terrible spiral of decline and leaves facilities that are not good enough to introduce young people to sport. If sports are to be taken seriously, people must learn to play them on a flat, well-cut pitch. There should be working toilets and not a boarded-up cubicle. Those factors may sound trivial, but they are crucial and not enough importance is given to them.

Allowing sports facilities to fall into decline is short-sighted and sad. It sends a poor message and fails to acknowledge the long-term impact on the lives and health of the local population. I ask the Minister to

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consider whether local authorities could be given a statutory duty to provide quality sports facilities to which everyone in their area has access. That would require extra funding, but sport is central to the Government's policy on crime, health, education and so on, and it would be money well spent.

In the run-up to the next spending round, and given Whitehall's traditional sidelining of sport, some will say that sport has had its lot and that it had its money in the last round, but I urge the Minister to accept that we have barely scratched the surface of what sport can do to turn round some of the intractable social problems in our deprived communities and inner cities. If we can keep ramping up the funding and make opportunities available to children, that can make the difference between drink, drugs and poor health, or a better path in life. It is that simple.

Some of the issues that I have raised go beyond the Minister's remit and it is difficult to tempt her on to ground that is not her responsibility, but I am sure that she also has strong views on the subject of public health. I hope that she will refer briefly to some of the issues that are the responsibility of the Department for Culture, Media and Sport and the Department for Transport, Local Government and the Regions.

I believe that the Government are committed to tackling health inequalities and the social problems that still exist in this country. They must acknowledge that there is a huge north-south divide which scars the country. They should make it a high priority to tackle that. Sport is an excellent place to start.

Mr. Edward O'Hara (in the Chair): There are 11 minutes left for each speaker before the winding-up speeches start.

5.12 pm

Dr. Evan Harris (Oxford, West and Abingdon): I pay tribute to the hon. Member for Wakefield (Mr. Hinchliffe), who is an admirable Member of Parliament and for a long time has been an admirable Chair of his Committee, which has produced an admirable report. I give him more than three out of four points, but I generally agree with him three out of four times. I share his scepticism about the NHS giving taxpayers' money over the odds to the private sector, which may then use it to poach more staff from the health service, further diminishing the capacity of the NHS. It is right that he shows that scepticism.

I certainly agree with the hon. Gentleman about the need for closer links between local authority social services and the health service. Indeed, he and I want each of our parties to go further for good health and economic reasons. We also agree about the importance of effective public and patient involvement at local level. I differ with him about a proscription on consultants working privately because, if there was a ban, I think that many would leave the NHS. If he thinks that we are short of 2,000 consultants now, I agree with him and the answer is to employ 2,000 more.

I pay tribute, as did the hon. Member for Wakefield, to my former colleague, Dr. Peter Brand. The hon. Gentleman said that he did not always agree with him. He was a fellow Liberal Democrat and a fellow doctor,

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but I did not always agree with him, notoriously so. However, he had huge experience, and was a charming man and, I understand, a great yachter.

The hon. Member for Wakefield started by stressing the shocking differences in life expectancy between socio-economic groups. He said that that was an indictment of health policy over the decades. I agree, but it is an indictment more of acts of omission than of acts of commission. I agree that correcting the difference takes time and is not, as other hon. Members have suggested, amenable to easy targets.

The hon. Member for Southend, West (Mr. Amess), atypically, stated that it was too early to make a judgment on the Government's strategy. I normally find him quick to condemn the other side and to praise his own. He was wrong to imply that the structural changes that the Government had made constituted the implementation of some of the recommendations in the Committee's report. As the hon. Member for Wakefield said, moving away from coterminosity by abolishing health authorities, and moving towards PCTs is moving away from the thrust of some of the recommendations of the report. Similarly, the abolition of health authorities and directors of public of health runs the risk of fragmenting the public health function, which the report rightly warns against. He was correct to praise Edwina Currie, who rightly sacrificed diplomacy on occasion, for speaking her mind. She was often right, and she continues to be right in many of her pronouncements on public health issues.

I was struck by the contribution made by the hon. Member for Stafford (Mr. Kidney). He was right to raise questions about the effectiveness of the Health Development Agency, not because of the lack of effort of people who work in it, but because one might question whether it has been given the right priority and is properly funded and resourced. I should have thought that a measure of its effectiveness would be that it made more headlines than did the Health Education Authority, which it replaced. It has failed to do that, and that is a worry. The hon. Gentleman was right to say that health promotion was often sacrificed to immediate ambitions; I recognise that that is a temptation for any Government, and restraint is required to avoid it.

The hon. Member for Wyre Forest (Dr. Taylor) gave some of the history of public health and mentioned Dr. Chadwick's motto "Cleanliness is next to godliness". When I grew up in Liverpool, they used to say that cleanliness was next to impossible. I do not think that that was directed solely at me, but perhaps it was. The hon. Gentleman also mentioned the advocacy role of directors of public health on behalf of the patient and the public. One of the worries that is borne out in some of the literature is that DPHs have been recruited as adjuncts to Government, which might have trammelled their independence. Public health stretches beyond medical matters, and people who are directors of public health have backgrounds other than medical, so I hope that they are tied more rather than less into being agents of Government policy or organisation.

The hon. Member for Harrow, West (Mr. Thomas), who is no longer present, raised what many of us as constituency Members of Parliament will recognise as the important issue of eating disorders. He stressed the enormous trauma that they cause whole families, let alone the sufferer, and the difficulties in accessing

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treatment. When a former Minister responsible for public health organised the body image summit, some scorned it and were sceptical and teased the Government. I was shouting, "Good on you," and would like to know from the Minister what has happened to that initiative. My worry is that the Government have been scared off. It is an important issue, and its profile should be raised.

The hon. Member for Harrow, West and others mentioned the importance of an alcohol strategy, given the huge cost in health terms of alcohol abuse. The funding for tackling alcohol problems is so much lower than that for other issues, and so much less than the alcohol industry spends on advertising its products.

The hon. Member for Bosworth (Mr. Tredinnick) raised some important points. We should not laugh at what he has said. He sets a challenge for those of us who believe in evidence-based practice, whether alternative or orthodox, as does the House of Lords Select Committee on Science and Technology. As the hon. Member for Wyre Forest said in his telling speech, we must provide the resources to ensure that alternative medicine can pass the evidence test.

The hon. Member for Brent, North (Mr. Gardiner), who is also not in the Chamber, was unfairly harsh on the hon. Member for Bosworth, but he made an important point about ensuring that screening programmes were accessible to those most at risk. Will we ever have proper screening for type II diabetes? That is important for the Asian population. A shortage of radiographers and radiologists may limit the Government's ambitions for screening. The hon. Member for Brent, North made an important point about health visitors, which we have discussed, and was remarkably strong in his call for much more sport in school. It is up to people like us to say what we would drop from a crowded curriculum in order for pupils to do more sport, or how we would fund an extension to the day. One has to be responsible about that. My hon. Friend the Member for Colchester (Bob Russell) would have shouted, "Hear, hear," to much of what was said on the love of sport.

The hon. Member for Leigh (Andy Burnham) is making a name for himself by his intelligent contributions and special knowledge of public health. He stressed health inequalities, income inequalities and the role of sport outside schools in communities. Sport is for girls, too. They are capable of antisocial behaviour, and we must think outside the box. That is a terrible expression; I apologise to the hon. Member for Southend, West.

I have a moment to talk about the Tobacco Advertising and Promotion Bill, which was introduced in the last Parliament. Many of us regret that a similar measure was not mentioned in the Queen's Speech this year, but the Bill is proceeding through the Lords as a private Member's Bill with the co-operation of the Government, or at least a lack of obstruction from them. My party is grateful for that, as our health spokesman in the Lords is promoting it. As the measures have been considered by the Commons already, will the Minister give the Bill fair wind if it reaches this House in much the same state in which it left it? It would reassure people if she were to say yes.

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We must tackle not only health inequalities but income inequalities. Without redistribution of wealth, we will never tackle health inequalities, or we will give ourselves less of an armoury with which to do so. The Government—it is not a matter for the Minister—must think about the importance of ensuring adequate redistribution of wealth to get rid of income inequalities as part of the strategy to deal with health inequalities.

5.22 pm

Mr. Oliver Heald (North-East Hertfordshire): I start, as did the hon. Member for Oxford, West and Abingdon (Dr. Harris), by congratulating the hon. Member for Wakefield (Mr. Hinchliffe) and his Committee on an excellent report. The investigation was thorough and extremely interesting. I would not have thought of Cuba as a health model for the United Kingdom, and I still would not do so completely. However, there are public health lessons to be learned from the concentration on sport, a theme that has been developed throughout our debate.

I have a little experience of running a youth football team in the inner city—it was down the Old Kent road—with the hon. Member for Eltham (Clive Efford). Many of the young people involved benefited hugely. Such teams were not widely available to them, and some of them would no doubt have become involved—they had been—in acts in which they should not have been involved. They valued being part of the team, and it kept them out of trouble. Following that experience, and from reading the findings in the report, I agree that sport is important.

The hon. Member for Wakefield and other hon. Members have made the point that given the organisational changes that are taking place, we should not have what the hon. Member for Oxford, West and Abingdon described as fragmentation. The changes that primary care groups and primary trusts are going through present a challenge on public health. There are widely held concerns that the timetable for change is demanding and ambitious, and that it may not be possible to put in place what is needed to meet it. The Royal College of Nursing and the BMA have raised that issue. The reforms have the potential to improve public health in the longer term, and primary care trusts are a good basis on which to proceed. However, if we rush the changes and do not deal clearly with public health, it could fall between two stools, as it has in the past.

The National Primary Care Research and Development Centre and the King's Fund, with support from the Department of Health, are working on the national tracker survey. The survey's research suggests:

It also suggests that there is a lack of managerial capacity and information in those organisations. The survey's project director says that

He says that the

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is important. He also notes that although many improvements can be made in the next two years, the worry is that general health improvement may take longer. Many others have expressed concern about the changes, and we should take the issue seriously.

One of the survey's conclusions on information technology, which is vital to implementing the changes, was:

Although there has been some progress in formulating plans for information management and technology and in increasing connectivity, shortages of skilled staff and resources make it doubtful whether key national targets will be achieved.

The Committee recommended that the national public health work force development plan and the public health skills audit should examine the issue to assess whether primary care has the capacity to take on public health responsibilities. However, the plan is still not available, and the Government's response makes me wonder when it will be. Will the Minister tell us when it will be ready?

The Committee commented on the role of directors of public health. It said that the way in which the role was framed was too vague and that directors had too little influence. Many witnesses voiced support for a joint appointments system for the role of director of public health. Given that we have now lost coterminosity and that the Government response talks of the Office for Public Management looking into matters, what point have we reached as regards the role of directors of public health? What does it mean when we are told that a study will be done at this late stage? Surely we should have an idea of whether there will joint appointments, how they will work and how the problem of coterminosity will be solved.

My hon. Friend the Member for Southend, West (Mr. Amess) said that school nurses played an important role in public health. The hon. Member for Brent, North (Mr. Gardiner) picked up on that when he spoke about the role of health visitors. It is vital to bear in mind that there are groups of experienced professionals who have been doing the job and providing a valuable service. We should not allow that body of experience and knowledge, which has been built up over years, to be lost. We should give those jobs the sort of status and importance in the system that they really deserve.

I was very taken with the Penwerris example from Cornwall. Health visitors Hazel Stuteley and Phil Trenoweth set up the project and developed all the ideas, which were not just about medical matters. In that, they differed from the Secretary of State, who was criticised by the Committee for constantly resorting to medical interventions. They came up with the idea that if the houses were insulated, people would be warmer. They came up with ideas to deal with a range of public health issues in their community. That seems to be a fine example of what can be achieved, so let us give health visitors the credit that they deserve.

On the question of children today being lazy, we have a duty to give them the opportunity to exercise. It is not simply a matter of sport. We live in a society where parents—I am a parent and feel this way—do not want

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their children to go to school on their own. However, ideas such as the walking bus, where the children in a community walk to school together, with one of the parents keeping an eye on things and ensuring that the children are safe, should be built on. However, we should ensure that we do not make the mistake that they made in Australia where, when a scheme for cycle safety was started and children were encouraged to cycle to school, the number of accidents on the roads increased. Things must be done sensibly, but such initiatives have much to recommend them.

My hon. Friend the Member for Bosworth (Mr. Tredinnick) mentioned alternative therapies. Although he always raises that point, and it is tempting to be amused that he managed to raise it again, it is not a laughing matter. His points are very serious and it is a cause for concern that, since fundholding ended, there has been a reduction in the number of therapists, counsellors and others in what could be loosely described as the alternative field attached to GP surgeries. In the mental health field, about which I know a lot, users value such services tremendously and find them useful. The Opposition's view is that if an alternative therapy can be shown to work, it should be made available.

I was going to speak at much greater length, and I shall not be able to pick up on every contribution to the debate. However, I would like to comment on the Government's record. I do not want to be partisan, but the record shows that the Government have concentrated on issues other than public health, and that is damaging.

5.33 pm

The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears ): I will do my best to deal with as many points as I can. I would like to begin by thanking my hon. Friend the Member for Wakefield (Mr. Hinchliffe) for his Committee's report, which is one of the most powerful reports of its type that I have read for a long time. It is wide-ranging, thoughtful, covers a huge range of issues in depth and gives the Government excellent food for thought. The report was matched by an equally powerful speech from my hon. Friend. His speech was complemented by all the contributions made today.

I am a little disappointed that there are no other women Members in the Chamber. Nevertheless, all the contributions have been excellent and I have learned a great deal about events in Members' constituencies, as well as about wider public health issues. I will want to consider further many of the issues raised.

In opening the debate, my hon. Friend the Member for Wakefield made a powerful point, illustrated by the recent confidential report on maternal deaths. The figures in that report were shocking, showing that women from the poorest backgrounds were 20 times as likely to die as women from better-off backgrounds. That sums up the whole tone of the debate. These are not just issues for discussion; they are real issues that devastate people's lives.

For far too long, public health has been talked about as an academic practice. The hon. Member for Wyre Forest (Dr. Taylor) talked about the study of epidemiology. That is a narrow definition of public

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health compared with what public health should mean to us. The Select Committee report and our discussions today emphasise the need to translate that knowledge and theory into practical action that makes a difference in communities. Perhaps we have reached a point in the development of public health when academic study can be translated into programmes that can be measured, so that we can measure performance and assess outcomes.

In its evidence to the Select Committee, the RCN said:

That is a telling phrase because it implies that public health has an impact across the piece, whether it is on people's lives, business, urban regeneration, crime and disorder, sport and obesity; all the issues that have been mentioned today. Public health is one of the most wide-ranging issues that we have to consider.

Several hon. Members raised the issue of the link between poverty and ill health. The hon. Member for Oxford, West and Abingdon (Dr. Harris) talked about the link between income inequality and ill health. For many years, making the links was taboo, but I am delighted that we now recognise the connection. Indeed, my right hon. Friend the Chancellor of the Exchequer has introduced many measures to eradicate child poverty—the working families tax credit, the national minimum wage, neighbourhood renewal, sure start programmes, massive investment in education, the new deal for communities and the fuel poverty strategy. Those are overarching methods of attacking underlying poverty and massive steps forward in improving people's health. For far too long, the issue of public health has been confined to the medical model followed by clinicians, doctors and nurses and other therapists. Valuable though that is, there are clearly bigger issues such as poverty that have a huge impact on people's health.

I believe that the report was designed to test whether the Government's action matched up to their rhetoric, following the Secretary of State's remark that it was time for public health to come out of the ghetto. Despite some of the issues that have been raised today, we have made significant progress in ensuring that public health is pushed up the agenda. I welcome the Select Committee's efforts in ensuring that it remains in the forefront of the Government's mind.

Many proposals that shift the balance of power and restructure the health service are designed to put patients and the public at the centre of the service. Several hon. Members raised issues relating to the new structure, because the report was completed before the proposals were made to shift the balance of power. People are rightly anxious to see that the public health function is carried out at local, regional, strategic and national level, and perhaps I can offer some reassurance on that point.

First, there will be a strong public health team in every primary care trust. It will engage with local communities and, crucially, with local government, which is responsible for many of the wider determinants of public health, whether that is a decent education, safe streets or warm and safe homes. The links between the primary care trusts and the local strategic partnership

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are key. In addition, we want to widen the primary care trust function to involve public health doctors and to bring in a wider range of professionals with relevant skills. I understand that work is taking place on training and accrediting people who are not from a purely medical background.

That picks up the point made by my hon. Friend the Member for Wakefield that, in the early days of medical officers for health—when environmental health departments had certain responsibilities—not only a medical model was applied. People from a range of backgrounds brought their expertise to bear on making progress. We will also ensure that there is a public health doctor with strategic management experience in every strategic health authority because, in addition to people who can deliver to local communities, it is important to have people who can take a longer-term wider view and consider where we should be going in the next 10, 15 or 20 years with our public health programmes.

We also want to be sure that a regional director of public health and support team are linked with each of the regional government offices. The latter will be increasingly responsible for a wide range of regeneration programmes. They will have the unified regeneration budget, so keying in public health with the regeneration role will give them a better and stronger role.

Capacity will be a problem. We must be creative about the sort of networks that we set up because not every area of public health in every primary care trust will have its own expert. As in other areas, I would like primary care trusts to collaborate with each other and to develop areas of expertise that they can share with their neighbours. They will not then run the risk of skimming through everything and doing a superficial job; instead, they will develop some depth and expertise that can be shared with the community through managed networks.

That is the way forward not only for public health, but for other parts of the health service that have capacity problems and where we need more skilled people. We must involve people in different ways; perhaps technicians will do jobs that others might have done, and nurses will do things that doctors might have done. We can try to break down those skills barriers to achieve a better skills mix, which will enable people to do much more. I hope that the new structure will strengthen the public health function, not fragment and dilute it.

The report mentioned a number of area-based initiatives, including partnerships, health action zones and education action zones; it also mentioned the difficulties caused by initiative overload. The only initiative for health is the action zone initiative. The regional co-ordination unit of the Cabinet Office is reviewing all area-based initiatives to try to simplify them, so that we do not have so many and that they can concentrate on simpler outcomes.

I am delighted to say that HAZs are in the first tranche of that review, but they have contributed to some innovative ways of working. They have sometimes engaged communities when the traditional ways of the health service were not able to. Health action zones have sometimes been able to use innovative ways of drawing in people, particularly those in ethnic minorities, and making sure that they can participate.

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We want to give HAZs space to keep their innovative edge and their "blue-skies" thinking, which we do not see enough of in the health service. We want to integrate them as far as we can into local strategic partnerships, so that they can influence not only local government but businesses, the voluntary sector and community groups. They will allow us to ensure that public health is at the heart of building healthy communities.

Mr. Heald : In her last two minutes, could the Minister say something about what will happen in terms of the huge rise in disease, including tuberculosis and sexually transmitted disease, and hospital infection?

Ms Blears : Obviously, all of those matters are of great concern. We have the sexual health strategy for sexually transmitted diseases, but it is not an easy thing to deal with. The hon. Member for Oxford, West and Abingdon said that tackling health inequality and public health issues would be one of the most challenging things that the Government could do, but we have not shied away from it. We have tackled some of the issues head-on; we know that they are of concern to our communities and that we need to take action.

Hon. Members have raised a wide range of issues. The hon. Member for Southend, West (Mr. Amess) expressed concern about school nurses and asked how they could be integrated into the system. We have a project to allow school nurses and health visitors to work together. We want to ensure that school nurses have a key role in the primary care trusts, because they are a valuable resource, as are health visitors. I agree

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with my hon. Friend the Member for Brent, North (Mr. Gardiner) that health visitors are on the front line. They can often reach families that others cannot, and they have done a fabulous job in sure start by making certain that, at the beginning of their life, children have the prospects and advantages that other communities sometimes take for granted.

My hon. Friend the Member for Stafford (Mr. Kidney) mentioned some of the practical issues that he had come across locally. I am delighted that he wants to ensure that public health is not an academic study, but that it should encompass smoking cessation, alcohol and drugs misuse. I welcome his suggestion that Members of Parliament should be ambassadors for such messages, and we shall ensure that that happens.

The hon. Member for Wyre Forest mentioned the advice of the chief medical officer, who told us not to smoke, to drink moderately, to keep active, to use sunscreen, to manage stress and to learn to relax. That is excellent advice for Members of Parliament.

My hon. Friend the Member for Harrow, West (Mr. Thomas) raised two particular issues. One was anorexia, and I assure him that we take it extremely seriously. The hon. Member for Oxford, West and Abingdon was concerned about the body image summit. We are not shying away from those issues and we shall continue to press them. My hon. Friend also mentioned alcohol misuse. We have pledged to bring a strategy forward by 2000, and we are on target to do that.

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