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Lord Higgins: I listened with great interest to what the Minister said and want to make a couple of points. He spoke of the 1998 SERPS; that is, the existing situation. Will he clarify the position of those in that scheme as the second state pension is gradually introduced? A number of people will want to stay in SERPS. At what stage will they be deprived of that option and what will be the situation of those who have not yet retired and those who have already retired?

Secondly, what will be the cost of the proposed arrangements for a state second pension--leaving on one side the issue of discounting the future value--compared with the cost of continuing SERPS in its present form?

Lord McIntosh of Haringey: The answer to the noble Lord's first question is that when a state second pension is implemented SERPS will end in the sense that no further pension will be accrued under it. However, pension rights already accrued under SERPS will be protected and paid in full. Therefore, any individual who works and contributes to both SERPS and the state second pension will receive a second pension based on both schemes on retirement.

As regards costs, the table is complicated and I do not have the ability to explain it at this Dispatch Box. Some of it is almost three-dimensional. Will the noble Lord allow me to write to him and place a copy in the Library of the House?

Lord Higgins: Yes, of course. I would be happy to do that. On the noble Lord's first point, am I to

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understand that effectively SERPS will become what one might call a paid-up pension and that the whole operation ceases at that point?

Lord McIntosh of Haringey: Yes. No further pension will be accrued under SERPS when the S2P comes in, which is not until April 2002.

Baroness Castle of Blackburn: The silence of large sections of the Committee on this issue just shows how complicated the whole pensions field is.

It has interested me, hearing Lord McIntosh's reply to me, to see how obscure and difficult the Government find telling the facts. May I on this point please ask Lord McIntosh if he will send me a copy of the relative costs that he is going to give to Lord Higgins? I would be delighted. If he can give them in a letter, for heaven's sake why can he not give them to the people at large? That is what I am asking; I am asking that everybody should be able to make these comparisons, and of course they cannot. I do not think even the Ministers can, or at least they will not.

I am not going to pursue the argument at this stage. It would be an abuse of the kindness of the Committee to make this a one-woman debate. I will therefore withdraw my amendment at this stage, unsatisfied as I am, and return to the matter later.

Amendment, by leave, withdrawn.

Baroness Amos: I beg to move that the House be now resumed.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

Public Health

4.31 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hayman): My Lords, with the leave of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

    "Madam Speaker, the new White Paper which I am presenting to the House today is called Saving Lives: Our Healthier Nation; and that is exactly what it is about. It spells out how we want to save lives by stopping people getting ill in the first place.

    "We are aiming to save 300,000 lives between now and the year 2010, by reducing the death rate from cancer in people under 75 by at least one-fifth; by reducing the death rate from coronary heart disease and stroke in people under 75 by at least two-fifths; by reducing the death rate from accidents by one-fifth; and by reducing the death rate from suicide by one-fifth.

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    "Those are ambitious targets which should mean that we become a healthier nation. They are bigger reductions than we suggested in the Green Paper; and unlike the Green Paper, these tough targets now apply not to people aged under 65 but to people under 75.

    "They are targets backed by action: on cancer--action against smoking, action to improve diet, action to improve screening uptake and quality, action to modernise cancer scanners and equipment, and action to improve treatment; on heart disease and strokes--action on smoking, diet, blood pressure, and exercise, action to cut heart attacks, and action to improve rehabilitation.

    "But that is only part of the story. We are not only setting tougher targets than the last government; we are explicitly aiming to do something quite different. Poor people are ill more often and die sooner. So we are going to tackle the inequalities in health which grew under the last government. Our policies are designed to improve most of all the health of the least healthy. The National Health Service has a big part to play, but our strategy requires a three-way partnership between the whole government, local communities, and families and individuals. None can succeed without the others. We reject the idea that individuals are powerless victims of their fate. But we also reject the Tory idea that individuals are entirely to blame for their own poor health.

    "We need to use all the means at our disposal to make it possible for everyone to lead healthier lives. Unemployment, low wages, poor housing, crime and disorder, lack of education and environmental pollution all make people ill. The Government are taking action to tackle them all. The windfall levy, opposed by both Tories and Liberals, is providing jobs and training for young people; and 400,000 more people are now in work. Low pay is a health hazard--so we will improve the health of over 2 million people and their families by our introduction of the national minimum wage. This autumn those families and many others will be helped further by the working families' tax credit. Many thousands more will benefit from having a decent home to live in as a result of our increased investment in new and better homes for people who are badly housed. And improved educational standards are providing economic opportunity and pathways out of social exclusion.

    "So the Government will play their part, but so too must communities. In some areas whole neighbourhoods are made unhealthy by poverty, pollution, crime and disorder. So we must target effort on those neighbourhoods. The most deprived areas are being helped by the extra effort and extra funding that flow from regeneration schemes, from health action zones and education action zones, from lottery funds going into healthy living centres, from the replacement of sub-standard GP premises, from the Sure Start programme for children, from the Healthy Schools project and from our £96 million Public Health Development Fund.

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    "We want to work with community organisations, local councils and health bodies to make sure these programmes are delivered on the ground. Every health authority will have to draw up and implement a health improvement programme which identifies and meets the particular health and healthcare needs of its area.

    "That is because priorities differ in different parts of the country, with different individuals and groups having different problems; for example, respiratory disease in areas of heavy industry or the higher incidence of heart disease or cancer in certain ethnic groups. Local councils, businesses and voluntary organisations will all be involved in developing and implementing these plans.

    "Fluoridation illustrates the new approach. The White Paper makes it clear that we will conduct an independent expert review of the safety and benefits of fluoridation. If it shows that fluoridation is beneficial, local authorities will be given new powers to require water companies to fluoridate where there is local support for doing so.

    "We also propose to strengthen the public health profession and to develop extended roles for health visitors, community and school nurses and midwives.

    "The new primary care groups will also enable GPs and practice nurses to draw upon their unique relationships with patients to help to promote better health. That is what many are doing already.

    "So we want action by government and action by communities. But that cannot be the end of the story. Individuals and families must also play their part. Smoking is the biggest single cause of avoidable death and the biggest single cause of inequalities in health. We have a twin-track strategy to stop the tobacco companies recruiting new smokers, and to help existing smokers to give up the habit. Unlike the Tories, we accept the overwhelming evidence that tobacco advertising helps to get children addicted--so the Government intend to play their part by banning advertising from December. But we also accept that individuals need help giving up. That is why we are making nicotine replacement therapy available free to poor smokers who want to give up.

    "This is a recognition of the fact that up to now most health promotion strategies have actually widened the health gap, because the better off have taken more notice than the worst off. We need to develop strategies which have most impact on the least healthy, and that is one reason why the White Paper announces our decision to replace the Health Education Authority with a new hard-hitting health development agency, with a much bigger role in working out and delivering those approaches that will work best.

    "Individuals and families can help one another. That is why we are launching a health skills programme that will give young people first aid skills and health information. It is why we are launching our expert patients programme to help people with chronic diseases like asthma and diabetes to manage their conditions better.

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    "This will be good for the NHS and good for patients, as fewer complications mean better health and less demand on GPs and hospitals, with resources used to tackle the highest priorities.

    "This White Paper sets out long-term plans for improving the health of the nation and reducing inequalities in health; and these really are long-term plans. Their full benefits will only show up in a decade or more. That is the time-scale involved, but that is no reason for delay. It is all the more reason for getting on with it: 300,000 lives saved--300,000 reasons for action.

    "Fifty-one years ago this week the National Health Service, which Nye Bevan founded, came into operation. We all benefit from the far-sightedness of that Labour government. They cut inequalities in access to healthcare but, by themselves, they could not reduce inequalities in health, but common justice requires that we do.

    "Members opposite representing areas where people are comfortably off and pretty healthy should recognise that ours is a simple but difficult aim. We want to help to make sure that the standard of health of the people they represent in Surrey or Sutton Coldfield is shared by the people we represent in Barnsley or Bethnal Green. That is what we mean when we say we want to end the divisions which mar our society--a genuine "one nation". I believe that that is what all decent people want to see, wherever they live and whatever their own state of health. That is why I commend this White Paper to the House".

My Lords, that concludes the Statement.

4.39 p.m.

Earl Howe: My Lords, I thank the Minister for repeating the Statement which I welcome, as I do the evident seriousness of purpose with which the Government are addressing those important issues.

I should say at the outset that I believe the Government are right to regard poor health as something which originates from a range of social and socio-economic factors such as housing as well as from causes which are more directly health related, such as smoking. Any credible plan to tackle public health must look across government as a whole and must involve society at every level.

In the short time that I have had to study the White Paper, it is rather difficult for me to comment on the detail of it. However, I should like to pick up on one or two points arising from what the noble Baroness said.

The Green Paper issued in February last year laid some considerable emphasis on the role of government, local government and individual responsibility. I was rather sorry that the Statement sought to portray the policy of the last government as focusing exclusively on the third of those matters. Incidentally, I do not know whether I am alone in finding the presence of barbed party political comments in the Government's Statement to be somewhat out of place. But we seem to be seeing rather a lot of those, in particular from the Department of Health.

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It is surely right for government to promote better health and to require health authorities to set appropriate targets in health improvement programmes. That very much follows the path set by the last government in The Health of the Nation White Paper of 1992. Nevertheless, without a recognition on the part of individuals that it is their choice of lifestyle which will have a major bearing on their own state of health, the whole exercise will inevitably falter.

The Green Paper spoke in terms of a national contract for better health. I wonder whether the Minister will enlarge on that concept today. In particular, what does the White Paper say about some of the major underlying causes of better health, such as good diet, food safety, exercise, moderate alcohol intake, sexual hygiene and so on?

The executive summary is critical of what it describes as the scattergun approach of the last government. But it was surely absolutely right for that government to lay emphasis, as they did, on the key causes of better health. I am unclear as to the extent to which the present Government's approach will permit that emphasis to be renewed. The fact is that the last government set themselves targets in 21 areas. Today's White Paper reduces that number to four.

The Government are to be commended on targeting their efforts most strongly on less affluent areas of the country. However, will the Minister say what that implies for the transfer of resources from what is termed middle England to poorer urban areas? How much money is to be retargeted from one to the other?

Again, in passing, I cannot help regretting the assumption in the Statement that Conservative Members of Parliament only represent healthier and wealthier areas of the country and are therefore, by implication, ignorant of the difficulties that tend to characterise poorer areas. Conservative MPs are aware of and sensitive to those issues, as are MPs of any party. Conservative MPs represent many deprived areas and, on this side of the House, we have every wish to see the nation as a whole benefiting from those initiatives. However, I believe that we are entitled to ask what the Government's policies will mean in practice in terms of the redistribution of the Department of Health's budget.

In taking through the recent Health Bill, now the Health Act, Ministers laid considerable stress on the need to iron out health inequalities, a theme which the Statement picks up. In answer to that point, on this side, we are all in favour of such an ironing out, as I said before, so long as it involves a levelling up.

It is somewhat ironic that as a result of devolution, we are likely to see three different standards of health implemented in the three countries of the Union outside Northern Ireland. Does the Minister recognise that one of the measures most conducive to the process of levelling out would be a government commitment to ensure that the availability of certain key groups of medicines is not prejudiced by unnecessary barriers? I am thinking in particular of statins, which is a class of drugs which has a proven value in reducing the risk of heart attack, atypical antipsychotics for the treatment

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of schizophrenia and cytotoxic drugs. For all of those, there is a marked disparity around the country in terms of the funding made available for them by health authorities.

The Secretary of State expressed the ambition in May to make our cancer services the best in the world and he added:

    "We know this will cost money". I applaud those sentiments but the inescapable fact is that the level of spending per head in the USA on cytotoxic drugs is about five times that in the UK. In Germany, it is over twice as much; and in France, nearly three times as much as in this country. The equivalent comparison for statins is equally stark. Will the Minister tell the House what more the Government propose to do to ensure that patients receive the drugs they need when they need them?

Osteoporosis is another important area of concern. The UK has the lowest number of bone density scanners in the European Union, a situation described by the National Osteoporosis Society as vastly inadequate. Will the Minister comment on that and say what action the Government propose to take?

Will she comment also on the targets for mental health? In particular, will she correct me if I am wrong in interpreting the targets set out in the White Paper as implicitly equating the state of mental health in this country with the incidence of suicides and that suicides and what are termed "undetermined injuries" are the only worthwhile measures in that area? I find that proposition instinctively difficult to accept. Finally, will the noble Baroness say what further primary legislation is implied by this White Paper?

I am supportive of the Government in the ambitions that they have articulated in the White Paper and wish them success in achieving the targets that they have set. I have no doubt that noble Lords will wish to hold the Government to account as the months and years pass and we see the fruits of the Government's efforts.

4.47 p.m.

Lord Clement-Jones: My Lords, I join the noble Earl in saying that I too have a great deal more reading to do of the White Paper and the attendant response to Sir Donald Acheson. But I also thank the Minister for repeating the Statement made in another place. Although the White Paper is making a belated appearance, nevertheless it is making an extremely welcome appearance. In particular on these Benches we welcome the fact that public health is now being treated as core to the health department. We welcome too some of the imaginative initiatives set out in the White Paper.

The Secretary of State said recently that promoting better health is not just a matter for the NHS or for social services; this is a job for the whole Government. The White Paper re-emphasises that, saying that it requires a three-way partnership between government, local communities and families and individuals. We welcome that partnership.

We also welcome the fact that there is indeed a new landscape. I believe that the treatment of public health issues is different under this Government. They link

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public health with social conditions. That was not done explicitly by the previous government. Therefore, I give this Government credit for that.

Health inequalities have widened over the past 20 years. However, the test is the implementation of the Acheson report and its 39 recommendations. Obviously, at a glance there is a great deal of response in the White Paper to the Acheson report's recommendations. But will the Minister be explicit as to which of the 39 recommendations have been accepted by the Government? They cover a wide range of areas; for example, tackling poverty, education, employment and transport. That is a wide variety of tasks which the Government are setting themselves.

In his report Sir Donald wanted the Government, above all, to put women and children first. Last week the BMA published a report which showed that the United Kingdom ranked 18th for deaths in early childhood. It is quite clear that public health policies should concentrate in particular on the first five years of life. There are correlations between low birthweight babies, future poverty, under-achievement and crime. Those are serious links.

Despite talk of joined-up government, however, the key question is whether the Treasury and the DHS will buy into the Acheson agenda. Is the Welfare Reform and Pensions Bill really working to improve public health? How did the withdrawal of benefit from lone parents contribute to improvement in public health?

We welcome the extension of some of the targets such as those for cancer and the other three areas. But why are there no national targets in other areas despite the responses to the Green Paper and the key issues raised by Sir Donald Acheson, such as the reduction of income inequality? If there is no target for a particular aspect of public health policy do we not risk being unable to measure progress? Therefore, does not the Acheson report risk the fate of the original Black report? Do we not need targets to understand what kind of vision the Government have in all areas?

As regards existing targets, what are the financial implications, particularly concerning cancer? It was recently estimated by CERT that in order to put the original targets in place a minimum of an extra £170 million was needed. The same is true for other targets such as coronary heart disease, mental illness and accidents.

We particularly welcome the development of health action zones and health improvement plans, which we discussed as the Health Bill went through this House. That means that we shall not be repeating some of the mistakes of The Health of the Nation which, despite many good intentions at government level, did not really reach down to grassroots level. I believe that the health action zones and the health improvement plans will do a great deal to make sure that the targets, limited though they may be, will reach the levels required. Those targets need to be locally owned. There are some signs that the voluntary sector is not becoming involved in the health action zones as they should be. I believe that East London and Hackney health action zones are a particular case. Will the Minister comment on that?

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We welcome the health development agency, as far as it goes. But does it mean that it is effectively a public health commission? For instance, will it have relationships with Scotland, Wales and Northern Ireland in the public health area? Will it be charged not just with overseeing best practice in England, but also best practice across the country? Who will now carry out health promotion campaigns? Will the agency also spread best practice between health action zones, which is so important in order to make sure that resources are used in the most effective way?

The White Paper mentions primary care groups. But will public health doctors be involved in the formulation of policy and its implementation in those primary care groups? We welcome the introduction of health impact assessments. But will they operate right across the board for all national government policies, and who will carry them out? I wonder what that will show if we subject it to the Welfare Reform and Pensions Bill and a public health assessment.

We welcome the fact that the Government have expanded their policy on children's safety. Although widely trailed, sports medicine is not contained in the White Paper. Can the Minister comment as to whether a sports strategy will be provided later in the year? One of the key areas for accidents is those caused during sporting activities.

A key aspect of public health is risk management and the communication of risk. We need to have a communications policy in place. That also was trailed, but I can see no sign of it in the White Paper. Can the Minister comment on whether the department will be taking on board the work done by the previous Chief Medical Officer as regards the language of risk? That would help enormously in terms of avoiding future problems such as BSE, E.coli and GM foods.

Finally, in common with the noble Earl, I suggest that a number of elements require legislation. What undertakings can the Minister give as regards early legislation? I thank her in advance for her reply. I realise that I have raised a number of questions. I would not like the Minister to believe that we do not welcome many aspects of the White Paper. We have started down a road which is quite a long one. The results may not be evident for some years, but it is very important that we set off in the right way with a very clear understanding of what the Government are trying to achieve.

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