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Baroness Anelay of St Johns: My Lords, as the Minister said, we are in comity on many of the amendments. She has made much of the arguments about racism and xenophobia. She will recall that I

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took care not to delete racism from the framework list. My amendment would delete xenophobia, because it is so generic as to be almost incapable of specific interpretation that would satisfy me for the purposes of relaxing dual criminality in that respect.

I could have done as my noble friend Lord Pearson of Rannoch did, and point to other generic offences that are objectionable for the purposes of the list, but on this occasion I was trying to narrow my fire. I shall consider further Amendment No. 329. On the first part of Amendment No. 329, I am intrigued by the fact that the framework list includes the word "and". In that case, if one is guilty solely of xenophobia does that mean that one does not fall within the list unless one has committed a racist offence also?

The framework list as currently drafted is not perfect. I will look at it again more carefully before Third Reading. I may not need to return to it, but I shall keep the matter open for the time being. As the Minister said, we are in comity on Amendment No. 181. In that respect alone, I commend the amendment to the House.

On Question, amendment agreed to.

[Amendments Nos. 183 and 184 not moved.]

Lord Bassam of Brighton: My Lords, I beg to move that further consideration on Report be now adjourned. In moving the Motion I suggest that the Report stage begin again not before 8.36 p.m.

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

Health Inequalities

7.36 p.m.

Lord Chan rose to ask Her Majesty's Government what progress has been made in tackling health inequalities, in particular in the North-West region of England.

The noble Lord said: My Lords, I am grateful for the opportunity to focus on what progress has been made in the Government's public health priority—tackling health inequalities. I thank all noble Lords for participating in this short but important debate.

I declare an interest as a non-executive director of the Birkenhead and Wallasey NHS Primary Care Trust and as chairman of the Minority Ethnic Health Task Force of the public health directorate in the Government Office of the North West. I acknowledge the assistance of Professor John Ashton, regional director of public health in the North-West, who is present.

I congratulate Her Majesty's Government for choosing to give top priority to public health and demonstrating commitment by the Prime Minister's taking a personal lead to oversee the production of a detailed programme of action to tackle health inequalities. Five specific steps were to be taken: tackling inequalities in access to health services; putting public health and addressing health inequality

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at the heart of the NHS; focusing on defeating our country's biggest killers, cancer and coronary heart disease; securing a better balance between prevention and treatment; and tackling smoking.

I may appear impatient in wanting to review progress of this long-term programme announced only last November, but I have looked in vain for any key publicity in the media on tackling health inequalities. That deplorable lack of interest is disappointing for the providers of innovative services and the hundreds and thousands of adults and children experiencing deprivation in England, particularly the north-west. Their plight is not clearly visible in the statistics for disease and death. They suffer disability, discomfort and despair. Their potential will not be fulfilled if local government and statutory agencies fail to help them to keep in good health.

Men and women in Manchester die seven to 10 years before people in south-west England. Residents in Liverpool and Blackpool are next among the worst off for life expectancy in England. The two primary care trusts in Wirral, where five wards are among the worst-off 5 per cent in England, identified six groups of people experiencing health inequalities in the public health annual report for 2003-04. The report states that those groups are: pregnant teenagers; mothers with young children in low-waged families; families affected by substance misuse; long-term unemployed men, usually fathers; the older husband and wife over 75 years; and the older person from a minority ethnic group. Health inequalities affect all age groups, from the babies of teenage mothers to older men and women, including ethnic minority people. Poverty is the common thread in all these vulnerable people groups. Poverty makes a normal life very difficult or impossible.

Our vulnerable people live in poor-quality housing. In Wirral, 30 per cent of housing stock does not comply with a decent homes standard and 6 per cent of housing fails the basic housing fitness standard. Poor people do not eat healthy food because it costs more than less healthy food such as fast food. Children whose parents have low incomes eat less fruit and vegetables than those whose parents have higher incomes. For example, in the Wirral, three in five children eat no leafy green vegetables, one in two do not drink fruit juice and one in five eat no fruit. Those children have poor dental health, are more prone to accidents and are more likely to die in house fires.

Females living in deprived areas are more likely to become pregnant at a young age than those living in less deprived areas. Therefore, four of the five highest wards for under-18 pregnancy in the Wirral are classified as neighbourhood renewal wards, receiving additional government funding because of their high levels of deprivation. Drinking excessive alcohol contributes to sexual risk taking, and that behaviour can lead to teenage pregnancy and sexually transmitted infection. Such infections are four times higher in the most rather than the least deprived areas according to the Public Health Laboratory Service report in 2000. However, there has been a national rise in sexually transmitted infection. Studies have also

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shown higher rates of gonorrhoea in some inner-city black and ethnic minority groups than in those from a white UK origin.

Very few towns and cities in the North-West now have shared social space that is not alcohol-based, especially for younger people. If non-alcohol-based public space for young people in regeneration planning is not available, we will further erode social cohesion and confound our aspirations for a multicultural society. That concern has been raised by the Health Development Agency.

In Wirral, people living in deprived wards have twice the smoking levels of those in better-off areas. Young mothers living in deprived areas smoke more than other women. They are also less likely to breast-feed their babies. Misuse of drugs, especially heroin, takes place primarily in the poorer areas in the Wirral, with large numbers presenting for drug treatment.

Older people who depend totally on state pensions are more likely to live with a long-term illness, including depression. They tend to have a greater need for health and social care services than those who are younger. Older people from ethnic minority populations are increasing in number as most of them migrated to the United Kingdom in the 1960s and 1970s. They are more disadvantaged than their white counterparts because they are not fluent in the English language, having spent many years in catering work. In Wirral and Merseyside, those older people from ethnic minority backgrounds are Chinese. They suffer social exclusion, living alone with limited contact with their children and friends.

In conclusion, I hope that the Minister will agree that now is the opportune time for me to ask what progress has been made in tackling health inequalities, especially in the north-west of England. The NHS and social services departments are doing their best, but they cannot adequately tackle health inequalities. Other partners must work together with them to focus on this task. It would therefore be helpful if the Minister could identify strategic cross-cutting work that he believes is reversing health inequalities of people living in the north-west of England.

I hope that he will also give examples of good practice to address the six groups of vulnerable people that I highlighted. Further, will the Minister also state how more emphasis can be placed on the prevention of ill health to match the great publicity given to medical technology and the treatment of disease? Finally, will the Minister outline how primary care can be given greater prominence in the perception of users of the NHS?

7.45 p.m.

The Earl of Listowel: My Lords, I thank my noble friend Lord Chan for tabling this important debate this evening and for making it clear to me that he wished to expand the parameters beyond the North-West. I propose to concentrate on the mental health of looked-after children. Listening to my noble friend's comments, I was reminded that the pregnancy rates among this group are unfortunately far higher than in

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the rest of the population. Also, there is some suggestion of greater exposure to class A drugs in this group. Perhaps that is not surprising, because 50 per cent of these children have experienced abuse or neglect before being taken into care. I also want to concentrate on a possible intervention that might be more widely used to improve the mental health of these children.

According to the Office for National Statistics, 45 per cent of looked-after children have a mental disorder. It is four times more likely for them to have one for than for those in the general population. I will also concentrate on the 7,500 children in residential care. They have even higher rates of mental disorder. The context of this is a CAMHS service in which there is a 12 to 18-month wait to see a psychiatrist in many areas. The group are also challenged because of the lack of placement stability that they experience—they may be moved from one area to another, their education may be broken down because of that and therefore the achievement that they might experience in school is undermined. Such achievement is important in improving mental health.

Another issue for these children is staff stability. There is a vacancy rate of about 18 per cent in London and 10 per cent nationally for residential childcare staff. There is a turnover rate of 15 per cent, which is 2 per cent higher than for social workers. To put that figure into context, the vacancy rate for police or teachers is about 2.6 or 1.5 per cent, so there is a background of instability in carers.

The minimum standards introduced for residential childcare are very welcome. We recently debated those standards briefly. The introduction of clear parameters for the supervision of staff is especially welcome. However, even the commissioner responsible for implementing the standards admits that they are the basic minimum. As I have said to the Minister in the past, I regret that the more sophisticated proposals in the report of the committee of inquiry into the selection of staff in children's homes, Choosing With Care, chaired by the noble Lord, Lord Warner—sometimes called the Warner report—and its emphasis on consultancy to staff groups in children's homes seem not to have been given the emphasis that they deserved. The report thoroughly endorses the involvement of appropriate mental health professionals on an ongoing basis as an efficient way of making use of scant child and adolescent mental health provision.

Three or four years ago, when I visited one of Centrepoint's projects, I was most impressed by the results that can come about. I had talked to outreach workers who worked with young people on the streets in Soho, and they had particularly recommended the project, particularly because it held on to difficult to look after children. When I visited the project, I found some troubled children. There was one young girl with many cuts from a razor across her wrist. There was a young Irish man who had been in and out of various hostels many times. There appeared to be good work going on inside that home. The staff there were

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supported once a week, as they should be, by an experienced child psychotherapist who came from outside the organisation to support them.

The staff worked with the most difficult client group in the whole Centrepoint organisation, and yet, as the manager went to great pains to point out to me, they had the lowest sickness rate in the organisation. Well supported staff working on the front line can be better retained and more easily recruited and have less sick leave. Those are important indicators.

At another children's home, I witnessed a consultation in progress and saw some of the great difficulties that come up. There were concerns that a girl who had been bought presents by a boy—a stranger—from the home might be led into prostitution by that young man. There were concerns about another child who appeared to be stealing from other children in the home. There were concerns about the difficulties of working with another agency. A highly professional, skilled consultant coming from the outside could help staff reflect on their practice and, perhaps, shed some of the burden of responsibility that they bore.

There are some difficulties with the approach. The principal one was identified in the Warner report. Consultancy is part of the professional development of staff and should, rightly, be the responsibility of the managers of children's homes. They should fund it. However, it also benefits the mental health of the children, so, in that sense, it is the responsibility of the health side. Who should take responsibility for funding it? That is one important issue. Who are the consultants? Are they mental health professionals and, if so, of what kind? Do they concentrate on the clinical case of each child? Are they other professionals experienced in advising teams on how to work together? Team work is a crucial element of the effective provision of childcare in residential children's homes.

There is also the issue of evidence. There is much evidence out there, but it must be collated. New research must be undertaken to verify the importance of the approach. Those issues are there, too. On the basis of my experience—over three years—of working in institutions in which children are cared for away from home, I value a partnership approach and feel that it is not sufficiently appreciated. The skilled clinician who used to go to the children's home to which I referred was deeply valued by the manager, but she had to fight tooth and nail to be able to work in support of the staff in the home. Her work was not valued by the organisation.

I welcome the Green Paper, particularly the partnership working that it describes. I welcome the children's workforce unit. It will have an important part to play in developing best practice. I shall write to the Minister in more detail on that matter.

In the mean time, I thank my noble friend again for introducing such an important debate. I look forward to the Minister's response.

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7.54 p.m.

Baroness Massey of Darwen: My Lords, I am grateful to the noble Lord, Lord Chan, for bringing attention to inequality in health. The problem has concerned politicians, administrators and health professionals for a long time. There has never been a better time to improve the situation. I say that because I am aware of a multitude of initiatives that should enable things to move on. In addition, there is a greater commitment to partnership working at a national and local level. Many doors are open, but more of that later.

I suppose that I should declare an interest as one who was born and brought up in the North West. The noble Lord, Lord Chan, gave us many facts and figures, none of which were surprising. The reasons behind the figures are less easy to pin down. It is encouraging that the director of public health in the North West, Professor John Ashton, and his colleagues have carried out wide consultation and are developing strategies to find the reasons and tackle them.

I have known Professor Ashton for a number of years and am constantly impressed by his tenacity and vision. I see that he is watching the debate avidly and appreciatively. In fact, we first met when I worked for the Health Development Agency, then the Health Education Council. That was in the mid-1980s. The report Inequalities in Health by Sir Douglas Black and his team had been published, the World Health Organisation had published its Global Strategy for Health for All by the Year 2000, and a report entitled The Health Divide had been written by Margaret Whitehead to update Inequalities in Health.

The World Health Organisation recognised that,

    "the undertaking to reduce health inequalities will remain an empty gesture unless radical steps are taken by government to seek better information, undertake large scale experiments, introduce anti-poverty policies, give priority to healthier lifestyles and monitor the effects of those on the health of the population as a whole and on the poorest groups in particular".

The Health Divide received a mixed reception. One response from Ministers was to accept that health inequalities existed but to say that they were due to individual behaviour such as heavy smoking, drinking and poor diet, rather than to social factors. Twenty-six MPs put down a Commons Motion calling for a programme recognising the relationship between poverty and ill health. In a debate in your Lordships' House, in 1987, Lord Kilmarnock said that, just as the gap between the richest and the poorest had increased within an overall increased national income and the plight of the homeless had become worse within an overall pattern of increased home ownership, so health inequalities had increased. He said that it was all part of the same pattern. That was in 1987, almost 20 years ago.

I meander back into history because, although much has happened to improve the quality of life, which leads to improved health, much has not happened. We now have a recognition by policy makers that health is not simply an individual matter, but is dependent on the social and economic climate, which preventive

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health should encompass. Health promotion saves money for the NHS, and good practice in health has to start early. I will touch on that in a minute.

There is commitment at a national and local level to strategies and practice that put substance on that recognition. I must refer briefly to the action taken by the public health directorate in the North West and to some action being taken for children, as was mentioned by the noble Lord, Lord Chan. I mentioned the importance of partnerships. The coming together of many structures in the nine Government Offices will help. One of the vision statements of the regional health group in the North West is,

    "to build upon the development of regional partnerships to improve the health of the population".

I am aware that consultation has taken place and that an action plan is due, I believe, by the end of November.

Consultation with and participation by the diverse groups in the community are vital, if people are to feel involved in solving problems in their community. Community involvement and action are important, as are leadership, advocacy and the building of workforce capacity. Underpinning all that, there must be research and analysis. I know that all of that is happening or is intended in the North West.

As I said, tackling health inequalities must start early. Sure Start exists to help families with young children. Schools must be involved, which, in turn, must include communities. The National Healthy Schools Standard, which I have been privileged to be involved in on several occasions, does just that. After discussions with parents and pupils, one primary school involved in the National Healthy Schools Standard completely redesigned the school meal system. The London primary school where I am a governor keeps a watching eye on health issues through its school council. Last year, it had a resolution about physical activity in the school.

As part of its outcome measures, the Green Paper, Every Child Matters, includes health and well-being, identified as important by young people themselves in a survey. There is the new NHS National Service Framework for Children, Young People and Maternity Services. Children's trusts are being developed. I hope that we shall see child and adolescent mental health services integral to all that. Importantly, we have a new Minister for Children to oversee the many initiatives aimed to foster children's health and well-being.

Some months ago, I visited Hounslow where a group of young people had explored health issues. They included youth peer research and a knowledge cafe event where the findings were presented to professionals in Hounslow, which encouraged interest, motivation and a sense of shared ownership. A key objective was not to simply identify health issues, but to gain insights into how young people understand and experience health in their every-day lives.

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I go back to the need for involvement, particularly involvement by specific groups; that is, not just young people, but women, men, black and minority ethnic groups. In his introduction to Investment in Health, Professor Ashton states:

    "Most health is gained and lost outside of medical care".

Perhaps we have over-medicalised health and, in doing so, have disempowered individuals and communities. As I said earlier, given all that is going on to redress the balance, we must seize the moment and ensure that we make a difference. Can the Minister restate the Government's commitment to reducing inequalities in health? Can he reassure us that similar initiatives to Investment in Health are taking place in parts of the country other than the North West? Can he say how we will monitor all this and learn from good practice?

In conclusion, I refer to the WHO statement Health for All in the Year 2000. Yes, it was aspirational. The North West has shown that it has moved from aspiration to action. I look forward to following the progress of those important initiatives.

8.2 p.m.

Baroness Greengross: My Lords, I congratulate my noble friend Lord Chan and other speakers. At lunch-time I realised that I could be here for this important debate and I am very pleased to take part in the gap. I shall focus more generally on health inequalities, rather than specifically on the North West situation, which my noble friend and other speakers have already done so admirably. I declare an interest as chair of the advisory board to the English Longitudinal Study on Ageing at University College London, led by Professor Sir Michael Marmot.

The study is funded partly by the American Government through the National Institute on Aging and partly by the British Government through the Department of Health. It follows a large representative group of people of 50 years old and over. It is designed to monitor how inequalities play out across the years and affect morbidity and mortality. The Centre for Health and Society at UCL was heavily involved in the Acheson inquiry in 1997 and has been since in other developments.

I first became interested in health inequalities in the context of the demographic revolution that we are under-going, but it has wider societal implications. Only two weeks ago on 13th October, we debated another aspect of this issue in the excellent short debate on obesity, which should be considered as one manifestation of health inequality.

Noble Lords may be aware of UCL's Whitehall study, which studied civil servant mortality rates in men aged 40 to 64. For the top grade of civil servant, mortality was half the average rate. As a result, we are lucky enough to have some of them here in this House. For executive grades, mortality rates were 20 per cent lower; for clerical grades, it was 35 to 40 per cent higher; and for office support grades, mortality rates were twice the average—a four-fold difference between top and bottom grades.

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Those are startling figures, which we have also seen in other areas—for example, on smoking, obesity, and so forth. To a great extent, that justifies the Government's focus on groups at the bottom of the scale. However, the UCL research is finding that the key group to focus on to make the greatest impact on outcomes is not necessarily or exclusively those at the bottom, but often the people just "below the middle". At an International Longevity Centre lecture in June, Sir Michael Marmot said:

    "the fact is that there is a social gradient . . . and these inequalities run right through from top to bottom".

However, that is not to say that we should not focus on those at the bottom of the scale at all. Sure Start is a very important initiative—which, in particular, looks at deprived neighbourhoods—that is open to all-comers. Getting the message about a gradient to policy-makers is sometimes difficult because, as we know, governments like to set targets. The target is the most socially excluded—those people right at the bottom—which is right, but these people should not be focused on exclusively.

The issue is very complicated: it is more complicated than just assuming that low income alone causes health inequality. For example, for black males in the USA, the median income is 26,500 dollars per year; in Costa Rica, it is 6,400 dollars per year. But life expectancy in Costa Rica is 75 years, compared to 66 years in the USA among the same group. What perhaps is more important is relative social exclusion—that is, how people feel within their own society about relative deprivation as well as actual deprivation; those things about which people are aware. Today, we are very aware of what is going on around us. It is not about genetic determinants alone; it is about things which we can see make a great difference—just like Seebohm Rowntree sought to do in the 19th century. To the credit of the Government, they are trying to do that.

It is crucial to take a life-course approach. I touched on that in the obesity debate; it is very important. The conclusion is that autonomy and control over one's life is another key factor in reducing inequality. Mortality rates must be reduced. It is very important to do so because not only are health inequalities unjust, but they are also grossly inefficient and something within our power to remedy.

8.8 p.m.

Lord Clement-Jones: My Lords, I congratulate the noble Lord, Lord Chan, on initiating this debate. While I do not have a particularly strong connection with the north-west region, when one looks at the figures it is clear that that region is uniquely deprived in terms of health inequalities. If anything, the noble Lord rather interestingly understated the problem. The North West still has the highest death rate of all the health regions in England. Breast cancer and male lung cancer rates continue to increase, in spite of falling national rates. Even the levels of lead found in drinking water are particularly high in the region.

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There is also a marked contrast between the health of those living in affluent, professional areas—there are quite a number of them—and that of those living in the areas of lowest income, concentrated in urban locations and other areas of social housing. Rates of long-term illness and infant mortality in those lowest income areas are almost double those of the more affluent, professional areas.

Children in the North West are more likely than on average nationally to grow up in lone-parent households or those with no one in full-time employment, which is reflected in their relatively poor health. Further, the infant mortality rate is 6.5 per 1,000 live births, compared with a rate of 5.8 per 1,000 for the rest of the United Kingdom. Those are very significant figures and it is in that context that we need to look not only at issues of how to tackle health inequalities in the region, but also more generally to see what effect current government policies have had.

Back in 1997–98, all welcomed the Acheson report and inquiry. The White Paper, Saving Lives: Our Healthier Nation, which followed, marked a major recognition that health inequalities are not caused only by health factors, they are influenced by a whole range of other factors. The key aims of the report, which received a wide welcome, were: first, to improve the health of the population as a whole by increasing the length of people's lives and the number of years spent free from illness and, secondly, to improve the health of the worst-off in society and to narrow the health gap. Those were laudable aims that sought to put public health at the forefront of public policy.

Even today, no one argues with the setting of the four priority areas. It is interesting that one of those key areas was mental health, so cogently discussed by the noble Earl, Lord Listowel.

Following the report, in January 1998, the Northwest Partnership established a regional action for health task group. More recently, the North West Public Health Team, based in the Government Office for the North West in Manchester and part of the Department of Health, has areas of responsibility which include working with regional and local agencies as well as the NHS to ensure that the wider determinants of health are recognised in policies and activities. Those are direct echoes of the lessons of Acheson. I found most interesting the comments of the noble Baroness, Lady Massey, when she spoke of the possible over-medicalisation of health policy: this is—to use a favourite Treasury expression—an area where cross-cutting must take place into other areas of policy.

The second limb of the effort being made by the North West Public Health Team is that of supporting the NHS by providing professional leadership development and intervention where appropriate. That, too, is extremely important. Further, as was mentioned by the noble Lord, Lord Chan, the Investment for Health plan is being carried forward.

All those efforts are important, but what is probably the more vital piece of work is a national one, because it looked at what kind of policies are needed across a

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broad front to tackle inequalities. I refer to the 2002 Cross Cutting Review from the Treasury, which identified that, despite increasing prosperity and a reduction in mortality over the past 20 years, there are still significant differences in health status between regions, between different social groups and so forth. Those differences between social groups are quite extraordinary. For example, life expectancy at birth between men in social class one and those in social class five widened from 5.5 years over the period 1972–76 to 7.4 years in 1997–99. Those figures can be replicated in different areas of the country. A similar comparison can be made of death rates in the North West and those in the leafier parts of London such as Kensington and Chelsea and Richmond.

One of the key lessons to be learnt from both Acheson and the Cross Cutting Review is that policies are needed to tackle inequalities not only in geographical terms, but also between different groups within the population. A further lesson was reflected in the point made by the noble Baroness, Lady Greengross, concerning the gradient of those inequalities which has been identified.

That means that, laudable though they may be, efforts such as the neighbourhood renewal strategies which target the worst-off areas are all very well, but they do not necessarily address the extent of the needs of particular groups such as older people living on lower incomes, children and other groups. Particular challenges are also presented by the needs of black and ethnic minority groups, disabled people and so forth. One needs a dual strategy that addresses both regional and local inequalities as well as inequalities within groups.

Some of the studies carried out by independent groups into the progress that has been made are very interesting. Particularly interesting is the UCL study undertaken by Mark Exworthy and colleagues, which was funded by the Joseph Rowntree Foundation and published in March this year. Although they say that some progress has been made, they identify three key gaps. First, a lack of mechanisms to promote and ensure progress in policies to tackle health inequalities; secondly, a need for an independent, regular evaluation of the progress of policies in terms of their impact on individuals, intermediate markers of progress and targets; and, thirdly, a need to conduct and collate research studies on effective interventions and outcomes.

They make some extremely practical suggestions. First, the role of the Inequalities and Public Health Task Force could be revised; secondly, the terms of reference of the ministerial sub-committee on social exclusion could be amended to include tackling health inequalities; thirdly, that sub-committee could be required to produce an annual progress report for Parliament; fourthly, a special, cross-departmental Select Committee could be formed, drawn from relevant departmental Select Committees. This may be a little mechanical, but I suspect that it is needed in order to get a genuine cross-cutting approach. The

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language now is "cross-cutting". It used to be "joined-up government", but we are trying to achieve the same outcome.

On the evaluation front, a mechanism could be created—possibly under the auspices of a new Select Committee or the Audit Commission—to scrutinise and independently evaluate progress, and mechanisms could be introduced to enable local authority scrutiny committees to include health inequalities within their remit. Those are very practical suggestions.

At the last general election the King's Fund produced an interesting briefing paper on inequalities in health. It questioned whether government policies had really made a difference. It states that many of the government targets have been limited to counting death rates for major illnesses; that the NHS still employs the majority of its energies on healthcare rather than on health improvement; and that much of the work taking place is small-scale, short-term in nature and not properly bolted into communities.

So there is a prescription. There are some extremely useful ideas out there. The Government's intentions have always been extremely good in this area but we still lack the mechanisms to get power behind the policy—and that is what is needed.

8.16 p.m.

Lord McColl of Dulwich: My Lords, I, too, thank the noble Lord, Lord Chan, for initiating the debate. I should like to explore the definitions of poverty and, more importantly, enlarge on the remarks of the noble Lord, Lord Chan, to illustrate how a simple behaviour change could result in those currently living in poverty having their health so much improved that they could be healthier than the rich.

The European Union definition of poverty is not particularly helpful—it is an income of less than half the European Union average. The World Bank has set the international poverty line at an expenditure level of one US dollar per person per day. As regards the present day interpretation of poverty, the general public hold ideas about the necessities of life which are rather more wide ranging than is ordinarily represented in expert assessments. People of all ages in all walks of life do not restrict their interpretation of the necessities to the basic material needs of a subsistence diet, shelter, clothing and fuel. There are social customs, obligations and activities that substantial majorities of the population also identify as among the top necessities of life.

People's perceptions of poverty tend to change as countries get richer. In this sense, the definition of poverty will always depend on what people in a particular society at a particular point in time perceive as "poor". A report by the Joseph Rowntree Foundation on poverty and social exclusion in Britain showed that the majority of people believe that it is more important to have heating in their home rather than to have a damp-free home. The majority nowadays also place more importance on a telephone than they do on a fridge freezer.

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The report concluded that since 1990 poverty appears to have become more widespread but not more severe. This would seem to indicate that it is a change of people's perception of poverty rather than the problem itself becoming more severe. A realistic definition of poverty is that in order to survive one needs adequate food, water and shelter. This will cost an individual, on average, in this country, £80 per week. This includes housing, council tax, food and fuel. A realistic present day situation is to take the example of an unemployed single person, aged 25 or over, who is in receipt of job seeker's allowance. He receives a total of £109.11 per week before housing costs. After rent and council tax, this leaves an individual with a total of £55 per week. This equates to the unemployed male, each week, being able to afford fuel and power for his house, the necessary requirement of food, a can of lager each evening, the luxury of a satellite television, any medicines and travel by bus. After all this, he still has £14 in his pocket. Nevertheless, it is quite clear from the noble Lord, Lord Chan, that the inequalities in the North West are very obvious, as the noble Lord, Lord Clement-Jones, has also mentioned.

Poverty is very closely associated with early death from heart disease, lung cancer and stroke in the North West. Our figures show that approximately 84 per cent of premature deaths in the North West from coronary heart disease can be attributed to poverty. Yet how do we know that poverty is the problem rather than a desperate need for a behaviour change?

Professor Sir Charles George, the British Heart Foundation medical director, said that the differences in the social class between rich and poor are the cause of thousands of deaths from coronary heart disease in the UK each year. He said:

    "People from lower socio-economic groups are more likely to smoke and less likely to eat fruit and vegetables than people from wealthier backgrounds".

The noble Lord, Lord Chan, has already mentioned that. Professor Sir Charles George continued:

    "They may also be less likely to report any warning signs of coronary heart disease such as angina . . . By helping people to change their lifestyles and increasing health education we can help turn the tide on these figures and reduce the devastating burden of coronary heart disease in the UK—for everyone".

With this in mind, I would like to point out six ways in which health could be dramatically improved without any increase in expenditure. The first way is food. In 1939, one third of the British people were underfed or fed on the wrong food. That figure obtained in the United States. The introduction of food rationing changed that overnight, as people ate the right food in the right quantities. The only obese people in those days were those on the black market. It was a high roughage diet and included the national loaf which was grey, not brown. Brown bread is brown only because it is dyed. Calcium was added to counteract the effects of phytic acid in the bran, which tends to prevent the absorption of calcium.

The first action, therefore, for better health, would be to eat the foods which are conducive to good health. A single man can buy such food in Sainsbury's in

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London for £25 a week—I have tried it. That includes wholemeal bread, five helpings of vegetables and fruit a day, eggs, fish, cheese, and so on. A single unemployed man seeking work has £55 a week. The first way to improve his health is to change his eating habits.

The second proven way of greatly improving health is to avoid all drugs which produce ill health. It is a cast-iron fact that smoking produces ill health and premature death. Stopping smoking not only improves health but leaves more money for a healthier lifestyle. An alcoholic binge in an evening can cost up to £100. Crack cocaine, for a buzz of a little over a few minutes, costs £100.

Then we come, thirdly, to safe sexual habits. In Uganda, President Museveni, one of the most outstanding leaders in Africa, was faced with a huge problem of AIDS and venereal disease in the 1980s. To the astonishment of the world, he achieved a remarkable reduction in new cases from 31 per cent to 7 per cent. How did he do this? His solution was to be honest and to encourage the people to change their behaviour by adopting the ABC policy. A is for abstinence, B is for be faithful in marriage and C is for condoms if you cannot do that. He was the first national leader to have the guts to say the obvious. Working with schools, churches and various groups, he got his message over—"Change your behaviour".

Fourthly, there is exercise, which is what the noble Lord, Lord Bassam of Brighton, frequently does. He goes for a run for miles around the streets of Westminster and appears as fresh as a daisy at the Dispatch Box, without a care in the world. I suppose that it is a relief to survive running around this place.

The fifth way in which to improve health is for those unemployed to offer their services free, particularly in charitable work. That happens on quite a large scale. Finally, housing can be improved by local charities, which may help the occupants of substandard accommodation to improve their premises by enhancing security, decoration and insulation.

Some noble Lords have mentioned improving NHS facilities but, apart from immunisation, the NHS has a very marginal effect on people's health. There are no easy solutions to tackling the health inequalities in the North West, which are extraordinarily complex. However, one solution is to increase the number of people who help those in poverty to improve their health by adopting more appropriate lifestyles. What is required are improvements in eating, housing, exercise, work and the avoidance of habits that maim and kill.

8.26 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner): My Lords, I am sure that we are all grateful to the noble Lord, Lord Chan, for putting the subject down for debate this evening. I assure him that the Government share his concerns, which he outlined so cogently. I shall try to outline what we are doing in the North West more generally and answer his questions along the way.

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We shall continue to publicise public health initiatives and developments and hope that a more balanced presentation can be provided in the media. I cannot always guarantee that we shall be able to compete with the latest medical technology in column inches, but we shall do our best. I reassure the noble Lord, Lord McColl, that I run regularly, although probably not as fast as my noble friend Lord Bassam.

Effective action to tackle health inequalities is particularly important in north-west England, given its relatively poor health, as several noble Lords have mentioned. The legacy of the Industrial Revolution is a region with a concentration of population in older, urban areas with high levels of poverty and deprivation—however one measures poverty—and a relatively poor environment, infrastructure, and housing stock. Given the constraints on time, I shall concentrate on the North West, but much of what I say has a wider application.

Male life expectancy at birth in Manchester is just under 70 years, the lowest of any local authority in England. Blackpool and Liverpool, with a life expectancy of 72, have the second lowest rates nationally. Unless substantial progress is made in tackling health inequalities in the North West, it will be difficult to meet national health inequality targets for the country as a whole.

Investment for Health, A Plan for North West England 2003, was launched in July 2003, and is the jointly owned strategy of the Northwest Development Agency, the North West Regional Assembly, the Government Office for the North West and the three strategic health authorities. I mention that because it is now common property across those different elements of government. The production of the strategy was co-ordinated by the regional director of public health for the North West, whose contribution has been recognised by several noble Lords.

The north west plan has its foundation in the Government's national strategy, Tackling Health Inequalities: A Programme for Action. The plan emphasises the need for more effective action across a range of sectors and agencies, to produce a positive impact on health outcomes by focusing on four priority areas.

First, there is tackling the wider determinants of health, such as housing, education and transport, and associated lifestyle and risk factors such as smoking, poor diet, and a lack of exercise. An example of that is the Food Development Network in North Cumbria, which was established to promote a healthy diet and local trade. The project connects farmers and communities and food is priced at a level that is attractive to both parties. The network supplies locally sourced fruit, vegetables, meat and fish through local food distribution networks. I hope that reassures the noble Lord, Lord McColl, that we are tackling dietary issues in some of these initiatives. The network is a partnership between the health action zone, Allerdale Borough Council, the Countryside Alliance, and local providers. It was established in February 2000. Outcomes to date include: 37 food co-operatives using

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local producers and reaching 6,000 people; fruit and sports initiatives in 42 schools and cooking on a budget courses reaching over 1,000 people. The network has improved access to affordable, healthy food in disadvantaged areas. I mention that as a concrete example of the kind of initiatives that are taking place.

To eliminate cold and damp housing conditions for people over 60, Merseyside health action zone has completed a project in Liverpool and St. Helens, Making People Feel Safe and Warm at Home. With elderly people it is not just a matter of feeling warm, but often of feeling safe as well. A package of home improvement measures was carried out on all properties to increase energy efficiency. Evaluation showed that residents felt warmer and more secure and had reduced heating costs. In addition, there were reduced demands on GP services from those involved in the project. The mainstreaming of the project is currently being reviewed.

The second priority area is ensuring that the NHS develops its role as a good corporate citizen by using its enormous social, economic, and environmental weight to support wider regeneration and sustainability objectives. I shall say a little more about that later.

The third priority area is mainstreaming measures to reduce inequalities in access to health and social care services and their quality and outcomes for underserved areas and groups. We have become very good at initiatives; what we need to do is to get those initiatives into the mainstream services.

The fourth priority is strengthening primary care services, and particularly staffing and infrastructure in deprived and underserved areas. Primary care trusts have a vital role not just in providing and commissioning services but in improving health and reducing inequalities within wider local partnerships. I hope that reassures the noble Lord, Lord Chan, on the priorities we are giving to primary care and the role of PCTs.

The key now is to take and integrate action in accordance with the north west plan, first, by making health improvement a cross-cutting theme in regional strategies such as the Regional Economic Strategy (RES) and, secondly, by ensuring that area-based policies address the need to reduce health inequalities. Primary care trusts are now required to produce local delivery plans to set out their programmes, and to agree health priorities with local authorities and other partners. Targeted area-based policies are particularly important in reducing health inequalities. For example, of the 88 local authorities in England eligible for neighbourhood renewal fund, 21 are in the north west region; that is virtually a quarter of the neighbourhood renewal fund initiatives.

An example of an initiative within a priority area is the Netherton Feelgood Factory in Liverpool. This uses a community development approach to enable people in a deprived area to improve their health. A shop in central Netherton acts as a base for a jobs and training service, a welfare rights service and a credit

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union. People are able to make appointments to see specialist advisers on the pensions service or lone parent issues.

A third form of integrated action comprises programmes for four specific priority groups: children and young people, older people, black and minority ethnic groups, and disabled people. The North West Regional Assembly has been running a major consultation exercise on disability and social inclusion over the past two years to take forward some of those issues.

A fourth area of integrated approach concerns tackling inequalities through programmes in everyday settings, particularly schools, workplaces and prisons. Schools provide a significant opportunity to deliver reductions in health inequalities. The National Healthy Schools Standard supports schools to invest in the education, health and well-being of the whole school community. Recent Ofsted research identifies schools in the Healthy Schools Programme, particularly those in disadvantaged areas, to be improving faster than similar schools not in the programme. I am cantering through as I know that noble Lords want to get on to the next business.

The noble Earl, Lord Listowel, raised the important issue of mental health and looked-after children. He knows my commitment in that area. He will be reassured to know that I have not resiled from anything I said in the Choosing with Care report. It is important, however, to know that we are making progress in reducing inequalities. There will be a review in an annual report to be published from 2004 showing what progress has been made. The noble Baroness, Lady Massey, rightly talked about the importance of partnerships. Evaluating partnerships locally is an important part of the new work.

I want to spend my last minute saying a few words about what the NHS itself is doing as a good corporate citizen. The Northwest Development Agency has taken action to improve health and reduce inequalities by making the NHS an investment for economic development, recruiting, employing and training more people from deprived areas to work in the NHS, using NHS purchasing and procurement to support the local economy, and ensuring that major capital schemes are assessed to identify opportunities for improving social, economic and environmental conditions in more deprived areas. Examples in North Huyton and Oldham show how those initiatives can be made to work.

In conclusion, well before my 12th minute, this has been a very thoughtful debate with some interesting perspectives. The Wanless report concluded that there should be more emphasis on prevention and public health measures, and on supporting the development of a population that was better informed and more able to manage its own health. I hope that I have shown that we are adopting that approach. Good work is going on in the North West to tackle such difficult issues, and it is very much a cross-cutting, joined-up government approach that works across the agencies and does not rely only on healthcare.

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