Health and Social Care Bill

My Lords, I am grateful to the noble Baroness, Lady Thornton, for so clearly analysing the different amendments. I shall keep to those that are grouped together. As she said, the gravamen of the amendments is towards the view that the duties of the Secretary of State and, indeed, of other bodies involved in the NHS should be strengthened and put in rather more forceful terms. Whether one prefers ““require”” or ““with a view to””, those words strengthen the position with regard to health inequalities from the rather low-level pressure of ““with regard to””. I say right away that my noble friend Lord Howe said, and I thought said very strongly, that this Bill contains a great many references to inequalities. It is also absolutely true that, as the noble Lord, Lord Turnberg, said, doing something about them is a very difficult exercise. One of the striking findings of the wonderful book The Spirit Level, which I have referred to before in this House, is that where there are grave inequalities in society, there are almost invariably grave inequalities in health as well. As the noble Lord, Lord Turnberg, said, the two are very closely related. Blame cannot be put entirely, or even largely, on the health service for the continuing inequalities. We know that there are very grave inequalities, both geographical and generational, between different parts of our society. To take only one example, lifestyles that feed bad health tend to be rather different between one section of society and another. I shall quote the words of the King’s Fund on the attempt made by the previous Government, to whom I give due credit, to deal with inequalities using the quality and outcomes framework. There was not much effect. The King’s Fund dismissed the whole effort with slightly contemptuous phraseology. It referred to, "““a medicalised and mechanistic approach to managing chronic disease””," which is fairly damning. In addition, we know that economic differences between regions are very often reflected in health outcomes and, therefore, that looking at health outcomes has to be related to other outcomes: educational, income and social. Let me therefore speak very quickly about some of the practical steps that can be taken to make the ethos and goal of this Bill more effective. The very first, which we will come to later, is crucial. It is taking public health from the Cinderella role it has had for many years to being seen as an essential part of a holistic health service. I refer to a series of articles in the Health Service Journal, the most recent of which appeared two weeks ago, about the failure to use modern communications much more effectively to get across to the public their own share in creating a better health outcome for themselves. All over London at the moment one can see in the windows of pharmaceutical companies, drug companies and so on abjurations to all of us to get ourselves a flu jab as quickly as possible. We also see, more widely, references to the dangers of smoking. Those are very simple examples of communications, but they could go a great deal further. If we can persuade our colleagues in public health and in individual clinical commissioning groups to use communications of the latest kind much more broadly and proactively, we would find one way in which to reduce the heavy demands made on the health service’s clinical and medical aspects. Let me give one example. Nowadays quite a few people with chronic illnesses have formed networks of patients. They exchange an extraordinarily advanced and sophisticated level of mutual knowledge and understanding about the use of new drugs, new techniques and even about how the way in which one lives can reduce the risks inherent in particular chronic sicknesses. I think that is absolutely right. At the heart of public health is not only treatment but, perhaps more importantly, education. We still have a long way to go in that respect to bring patients into the business of helping to look after themselves, so my first question to the Minister is: how far are we putting emphasis on new communications technology as part of the future of public health? The second thing I want to mention is the importance of clinical commissioning groups looking at the real danger, which was spelled out by Mr Dalton, the director of a PCT cluster, of creating what he called sink estates: clinical commissioning groups that end up with all the tough cases in an area. As we move towards coterminosity, I hope we will move away from that risk, but one cannot completely rule it out. It is something that a very close eye will have to be kept on by the clinical Commissioning Board to ensure that we do not see the creation of groups that are underfinanced, or at least, perhaps, underqualified, ending up with the hardest cases in the community. I promise that I am not going to go on for very much longer, but thirdly, I believe it is of great importance to ensure that as far as possible—and this is caught up in the amendment to which the noble Baroness, Lady Thornton, referred—publicity is given to the inequalities continuing in health so that we become more aware of the extent to which health inequalities could be tackled, possibly by methods other than simply health itself. In that context I say rather loudly and clearly that I find it rather hard to understand the distribution of funds to local authorities on the basis of the so-called non-chronic expectation of life figures—which seem to have bitten very hard on some of the poorest communities in the country—and to emphasise that it is important for those who are dealing with a health service to look at their relationships with other government departments to ensure that the one objective is supported and helped by the others. I am worried that areas such as Knowsley, Merseyside and Manchester appear to be among the heaviest losers at a time when we are trying to bring social care and health together. The final instance I want to give, which I think is also very important, is the crucial role in this respect of the health and well-being boards. I pay tribute to the Government for the role they have given to health and well-being boards. We are only at the very beginning of the development of the strength and influence of them. To take one example, I hope we will move towards a situation where the health and well-being boards not only are consulted by the clinical commissioning groups but their support and approval is required before a clinical commissioning group can go ahead with the business plans it has for its neighbourhood. To conclude, the mobilisation of health and well-being boards behind the concept of a fairer and more equal health service is an absolutely crucial potential we all need to help realise.