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Baroness Hayman: My Lords, I am grateful for the contributions of the noble Earl and the noble Lord and, perhaps most of all, for the recognition by the noble Lord, Lord Clement-Jones, that he raised a wide range of questions. I shall do my best to answer the broad issues raised by both speakers.

As regards his remarks about inequality, that ties in with the issue that the noble Earl, Lord Howe, raised about there being real differences in approach to those matters. We cannot avoid recognising those differences. They are reflected in the attitude of previous Conservative governments to the Black report and of this Government to the Acheson report.

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The noble Lord, Lord Clement-Jones, asked about work to take forward the health inequalities agenda together with the White Paper, which makes it quite clear that we have dual aims for a public health strategy. One is improving the health of the whole population and the other is improving the health of those who are worst off and most deprived so that we narrow the gap that has been widening in previous years.

Together with the White Paper we have published another action report on reducing health inequalities. It recognises in particular the range of government activity necessary if we are to make a real impact on poor health as well as on health services. That means work to tackle poverty and deprivation, poor housing, lack of facilities, and providing access to fresh food at reasonable prices and decent public transport. In those areas people suffer from multiple deprivation which is reflected in ill health. That is why we have a separate and parallel publication on the action that we are taking.

For example, the social exclusion unit concerned with teenage pregnancies recognises the need to tie up issues concerned with social security, financial support, access to work as well as access to information and services. For example, investment in education can have an enormous effect on the health of individuals.

The noble Lord, Lord Clement-Jones, asked whether it was a matter of women and children first. Women are certainly key determinants as regards the health of families. There is much international evidence that investment in the education of women results in the improvement of health of children and populations. That is something that we have to recognise. The Sure Start programme reflects that recognition. It is recognised in the targeting of work within health action zones and in the funding for smoking cessation services. There we find the answers to the questions of the noble Earl, Lord Howe, about targeting resources to the areas where there is most need. I agree with him that we are here seeking to level up rather than level down.

The noble Lord also asked about equality of access to effective medicines. We are taking action, for example, on psychotropic drugs in terms of reference to the National Institute for Clinical Excellence to make sure that the same evidence base is used by health authorities. On the issue of statins, we have the National Service Framework for Coronary Heart Disease. Looking at the National Service Framework for Mental Health, we see that we recognise the need to focus on a whole range of services to improve mental health.

The noble Lord made the point that reducing suicides is a rather crude measure of improvement in mental health services. The National Service Framework for Mental Health will address the unacceptable variations in service across the country. However, we recognise that health services alone cannot prevent suicides.

This is a clear, focused document on saving lives. The interim report of the national confidential inquiry into suicide and homicide by people with mental illness, directed by Professor Louis Appleby, found that there is scope for improvement in providing services which are integrated and which do not leave people suffering from

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mental illness unsupported at times when they are most vulnerable. Having a suicide reduction target will require a concerted effort towards primary prevention, secondary prevention and treatment which I believe will have an effect throughout the provision of care for those suffering from mental illness.

On the issue of whether there are too few targets at national level, it is our belief that four national targets, focusing on the four major causes of premature death and avoidable ill health, will be tougher for the Government but that it is right to focus on delivering on those. If we are to deliver on clear targets, it is necessary to work across a whole range of activities.

I recognise that the White Paper is a big document which people have not had a long time to study, but it clearly shows, in the partnership that we are seeking, how the allocation of responsibility between the individual, the local community effort and national government will be tied together. However, there is scope in local health improvement programmes to set targets that address the specific local health issues that arise.

The noble Lord, Lord Clement-Jones, asked whether there would be a sports strategy. The Department for Culture, Media and Sport is developing a sports strategy, to be published later this year, to promote greater scope for participation in sport and physical activity for all. I believe that the noble Lord was approaching the problem from a different viewpoint. I was looking at the issue of exercise as an important determinant of good health; he was looking at the risks in exercise and sport in terms of causing injury.

That leads to another element in the strategy which is the improvement in the first aid skills of the population as a whole, which can be as applicable on the sports field as at home or in school. Out-of-hospital care delivered by people who know the basics, at least, of first aid will be a tremendous help in a variety of situations.

As the noble Lord suggests, risk is a difficult area. It is included in the White Paper. Currently, the department is developing principles for producing policy and is using risk analysis to interpret information. Earlier the noble Lord mentioned the extremely important initiative to try to ensure that departments across Whitehall--including the Department of Health--and individuals can base their personal decisions, as well as government decisions, on well evidenced information. I believe that the communication of risk is one of the biggest challenges for our scientific and political communities. At the moment, that is not carried out in a consistent manner.

As regards the issue of legislation, the White Paper will be followed by secondary legislation to convert the Health Education Authority into a new health development agency. It is not our belief that other legislation is necessary to implement the White Paper. A great deal of other actions by a wide range of people are required in order to do that, but they do not depend on legislation.

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5.06 p.m.

Baroness Gardner of Parkes: My Lords, the issue of fluoridation is mentioned on page four of the Statement. At a time when 2.5 million fewer people have National Health Service dentistry than when the Government came into power, at a time when the most under-privileged children have deplorable dental health and suffer unnecessary pain from decaying teeth, why are the Government suggesting an independent expert review; yet another review? Can the Minister tell us what form that review will take and whether it will include any pilot studies? How long will that delay the introduction of fluoridation? Will the matter be settled before the next general election? How can the Minister say,

    "Fluoridation illustrates the new approach"? Is the new approach to avoid decision-making, to delay again and to review again and again? When shall we see such legislation and help for the desperately unhappy children suffering dental pain?

Baroness Hayman: My Lords, I respect the commitment of the noble Baroness to this area. I believe that she knows that I personally share her views on the benefits of fluoridation. However, we should deceive ourselves if we thought that our views were shared by everybody. We want to tackle dental health inequalities and we want to end the current legislative impasse. It is no good pretending that everything has been working satisfactorily up to now.

Since 1985, 55 requests from health authorities have been turned down and nothing more has happened. We want to overcome that. There is a view that the evidence on the safety of fluoride is based on studies conducted some time ago. That is why we have asked Professor Jos Kleinen at the NHS Centre for Reviews and Dissemination at the University of York to lead the review. The report is due early next year. Once we have that report, and if there is no doubt about the safety of fluoridation, we can take the kind of action that we believe would be effective.

At an optimum level of one part per million fluoride, dental decay in children is reduced by between one-third and one-half. We want a targeted programme to tackle dental health inequalities. Some 25 local authority areas now fluoridate their water. If another 25 local authorities fluoridated their water--say, in the North-West, East London, East Midlands, Southampton and Bristol--we would make an enormous impact on the problem. No other oral health promotion measure is anywhere near capable of reducing the rates of tooth decay in deprived areas to the levels in affluent areas. That is why we believe that we have to find a way of negotiating ourselves out of what has been an impasse for many years and take effective action. If the matter takes a few more months but produces more legitimacy for the policies of the future, I believe that will be worth while.

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