Health Inequalities

I beg to move,

That this House has considered legal duties on the Secretary of State to reduce health inequalities.

It is a pleasure to serve under your chairmanship, Mr Hollobone, and I am delighted to have secured this debate and to raise this important issue.

In 2016, the Health Committee Chair, the hon. Member for Totnes (Dr Wollaston), led a thoughtful and important debate on this issue, noting that in the Prime Minister’s first speech in No. 10 Downing Street she had put reducing health inequalities at the top of her list of priorities. But July 2016 is now a very long time ago, and since that date we have heard a great deal less about that injustice. During that time, inequality of health outcomes between those in affluent areas and those in areas of deprivation has persisted.

That injustice has been obscured by improvements in overall health outcomes—and, of course, by all the other business that has been going on in this place and distracting us from the reasons that so many of us came to Parliament. As the Government unveil the NHS 10-year plan, it is right that we make a conscious effort to revisit the question of health inequalities. I want to do so in particular because I can see unequal health spending by local clinical commissioners in my area. While decision-makers may pay lip service to tackling health inequalities, it is not the driver that it is meant to be under the law.

Of course, the primary causes of health inequalities are complex and varied, from unemployment to poor housing. While no one would suggest that healthcare spending is the answer, we must ensure that all healthcare decision-makers understand their duties and the importance of their obligation to provide access for, and direct spending toward, those most in need. Healthcare spending is the one part of the mix that Government can control, and it is right to expect healthcare spending to be focused on tackling both unequal health outcomes and unequal access to healthcare.

The allocation of funding to local commissioners, which the Minister will probably touch on, rightly includes an adjustment for health inequalities based on the mortality rate. An area with a higher mortality rate, such as my borough of Telford and Wrekin, will get more funding per head than an area with a lower mortality rate, such as neighbouring Shropshire, but that is not the end of the matter, particularly when it comes to major hospital reconfigurations, which are happening in so many places across the country.

While funding may be allocated to separate clinical commissioning groups on the basis of need, when it comes to a major reconfiguration, CCGs will group together to form a joint CCG, bringing widely disparate areas under their umbrella. The funding and resource decisions are then made by the joint CCG, without considering health inequalities between those disparate areas. That is exactly what is happening in my area.

Telford is a post-war new town, created on the east Shropshire coalfield, and it has areas that are among the most deprived in the country. It has, by every measure, significantly worse health outcomes than Shropshire, a county that has better health outcomes than the national average, and significantly better outcomes than Telford, by almost every indicator.

We are experiencing just such a hospital reconfiguration. Telford and Shropshire have combined, and funding for hospital care is allocated to the area as a whole. What we have seen is a joint CCG, representing those disparate areas, deciding to direct the bulk of its funding to the more affluent area, and to move existing resources there from an area of deprivation. That is a clear failure of the duty to narrow health inequalities.

The national health service database has the figures there for all to see. When it comes to health outcomes, Telford and Shropshire are at different ends of the spectrum. For someone living in Telford, the premature mortality rate is 25% higher than for a person living in Shropshire. Children in Telford are far more likely to suffer from obesity or to be hospitalised for dental decay. Tragically, rates of suicide and cancer in Telford are significantly higher than in Shropshire. Smoking rates, inactivity in adults and other such indicators show the very same disparity. The truth is that a shire town in rural England is healthier than a new town built in a former mining area on the east Shropshire coalfield, and NHS spending allocations are required to recognise that greater need. It is that simple—yet in practice, that is not what is happening.

The Health and Social Care Act 2012 makes it clear that there is a requirement to move towards greater investment where levels of deprivation are higher. Under the Act, that is a legal duty on the Secretary of State, NHS England and CCGs. The guidance makes it clear that inequalities

“must be properly and seriously taken into account when making decisions”.

As a former non-executive director of an NHS trust, I know that the NHS constitution requires the NHS to pay attention to sections of society where improvement in health and life expectancy do not keep pace with that in the rest of the population.

It is not enough for the Government or NHS England to hand over the cash to a joint CCG and then say, “Job done,” as far the health inequality duty is concerned. CCGs also have a duty to narrow health inequalities and, if they are not complying—as in my area they are not—I ask the Minister how we can hold them to account. What steps can be taken to enforce that requirement?

This is happening not only in Telford. Across the country, from Lewisham to Huddersfield, the NHS is carrying out controversial restructurings of hospital care similar to the one in Telford, where funding and resources are being targeted toward a single area. If what is happening in Telford is happening elsewhere, decision-makers are ignoring their duties to address inequalities—or maybe they are merely paying lip service to them. It is all very well to commit to narrowing health inequalities, but that commitment is manifested only on a spreadsheet when we do our allocations to CCGs; it is not happening in practice when it comes to spending that allocation of funding.

I am grateful to my hon. Friend for securing this important debate. In my area, East and North Hertfordshire CCG is being forced to merge its management and executive teams, but so that it does not have to consult with local people, it is going to keep three separate boards. As a result, we are concerned about how decisions will be taken going forward and, although the spending will be going to the three separate CCGs on paper, in reality one committee will be making those decisions and getting the boards to ratify them. The concerns she is raising in her area are repeated around the country.

I thank my hon. Friend for his intervention, and I am aware of the position he sets out. He is absolutely right; these problems are happening elsewhere with the combination of CCGs coming together and not being able to meet the needs of the individual areas that are receiving the funding.

In Telford, the local hospital trust serving both Telford and Shropshire announced in January, after five years of bizarrely convoluted and contorted deliberation, that it was pleased to announce its investment of a total pot of £312 million in a state-of-the-art critical care unit in the leafy, affluent shire town of Shrewsbury in Shropshire, 19 miles from Telford. In addition, the trust announced that it was pleased to say it would transfer Telford’s women and children’s unit and emergency care from Telford to Shropshire.

I have repeatedly asked the revolving door of hospital management over the past five years to explain how that proposal narrows health inequalities, how that decision improves the health outcomes of the most disadvantaged groups in the area they serve and how it improves health access for the most disadvantaged group if it is moving their provision 19 miles from its current location.

The response to my questions over a significant period has been to take no notice whatever. As an MP I have found, and I know from talking to them that many colleagues have also found, that local hospital trusts and CCGs feel no obligation whatever to respond to or even take notice of elected representatives. Indeed, my right hon. Friend the Member for Hemel Hempstead (Sir Mike Penning) noted in this place just last week, in an excellent debate on his local trust, that he had “absolutely no influence” on any decisions made by the CCG in his area.

As the Shrewsbury and Telford trust felt no obligation to respond to questions on this incredibly important issue, I asked the then Secretary of State if he could seek a response on my behalf. However, even that did not bring so much as an acknowledgement that reducing health inequalities is an important issue for the hospital trust or the CCG when making spending decisions.

My hon. Friend will be aware that there are health and wellbeing boards at play in local authorities. How effective has her local health and wellbeing board been at holding the CCG and other parts of the NHS to account, not only for their spending decisions but for how those decisions impact on frontline patient care?

I thank my hon. Friend for sharing his expertise in this area. My local council and health and wellbeing board have equally not been listened to on this issue. It is a Labour council, but it has tried extremely hard; if there was an opportunity to suggest otherwise, I would perhaps take it, but that is not the case. Both tried hard and have not been listened to. Most frustrating has been that the voice of local people has not been heard. Who do we expect to enforce this statutory duty? We cannot expect constituents to crowdfund a legal process because we want to hold CCGs to account.

Does the hon. Lady share my concerns on integrated care providers? Those should be statutory bodies and not in any way open to being private companies, which can hide behind commercial sensitivity, for exactly the reasons she says.

I thank the hon. Lady for her comment. There was an interesting debate on that issue on Monday night in the Chamber. This is an important issue, and I have a lot of sympathy with what she says.

On the injustice of unequal health outcomes, I said at the outset that that is of course not about spending more, and that poor health is not only about healthcare but is a much wider issue. However, if the NHS overlooks its statutory, constitutional and moral duty to properly consider health inequalities when making major spending decisions, the Secretary of State has a legal duty to act; he cannot just sit on his hands and say it is down to local clinicians. That response is all the more frustrating in my case because all six voting members of the Telford CCG voted against the transfer of resource from an area of deprivation and to an area of relative affluence, whereas all six voting members of the CCG in the more affluent Shrewsbury naturally voted for the funding resource to be transferred to their area.

In our case, Telford CCG was made to vote again until it came up with the right answer and allowed that transfer of funding. [Interruption.] That is very topical, yes. This whole issue reminds me exactly of Brexit. I wish I had not come on to that point; this should be a Brexit-free zone, for a change, so that we can all maintain our sanity. However, it is similar in the way that those in power have not been listening to the people. It is extremely important to note that, if we give that sort of funding to relatively affluent areas and take resource away from the most disadvantaged, we are doing something wrong. No Government could think that that was a good idea. I am grateful to the new Health Secretary, who came to Telford to visit our Princess Royal Hospital earlier this month and took the time to see for himself the fantastic work being done in the very areas that the management is seeking to close and to transfer 19 miles away to Shrewsbury hospital.

The debate can last until 5.30 pm. I am obliged to call the Front-Bench spokespeople no later than 5.07 pm. The guideline time limits are five minutes for the Scottish National party spokesperson, five minutes for Her Majesty’s Opposition’s spokesperson and 10 minutes for the Minister, with the mover of the motion having two minutes at the end to sum up the debate. The next 18 minutes will be for Back- Bench Members. You can all contribute if you speak for no more than four and a half minutes each.

I congratulate the hon. Member for Telford (Lucy Allan) on bringing this issue to the House. I am always very pleased to support her on any issues that she brings to the House. They are always ones that I am interested in, and that is why we are all here—because we are all interested in this issue.

The issue of health inequalities is of grave concern to me, as I hail from what too often feels like the poor relation when it comes to health issues—Northern Ireland. Our NHS is stretched beyond capacity and without access to many services that the UK mainland has. I suspect that when we hear from the spokesperson for the Scottish National party, the hon. Member for Central Ayrshire (Dr Whitford), she will tell us how things are progressing in Scotland, and I always feel envious of things that are being done there. I wish that we could replicate them in Northern Ireland.

People in Northern Ireland do not have access to children’s heart doctors. Parents and their sick children have to fly to the mainland or travel to the Republic of Ireland. Over the years, a number of my constituents have fallen into that category. It is because we do not have enough demand on paper to keep a paediatric cardiology team in place, yet in practice far too many children are having to travel, with no family support, out of Northern Ireland to London or to the Republic of Ireland. They are treated unequally because, let us be honest, they come from Northern Ireland. The access that they have is not the same as people have on the mainland. The fact that they are going to London or to the Republic of Ireland is an indication of the problem.

Then there are those who suffer from rare diseases, who feel the inequality of suffering from something that is not common enough for there to be a focus on it or for funding to be put into it. That is heartbreaking. When we consider that 54% of UK cancer deaths are from rare and less common cancers, we suddenly realise that it is so wrong that there is such inequality in funding across areas including policy, services and research. In particular, symptoms of rare and less common cancers can be less well recognised or vague and, as a result, too many people are diagnosed late or through a presentation at an accident and emergency department, which generally means that outcomes will be much poorer.

I congratulate my hon. Friend the Member for Telford (Lucy Allan) on securing the debate. This is such an important subject. A Cornish MP absolutely understands health inequalities and the lack of funding to target them. In Cornwall, there is no shortage of examples of health inequalities. I will mention just a few issues: vascular disease, including diabetes, kidney disease, dental health problems, skin cancer, diagnosis times for people with severe conditions, including ankylosing spondylitis—I chair the relevant all-party parliamentary group for that—and mental health services. It is clear that in Cornwall there are inequalities in all those areas.

My hon. Friend was right to address the need to allow funds to be targeted towards health inequalities. As a Member for Cornwall, which has long been underfunded compared with the rest of England, or at least the English average, I fully support that. However, in the short time that I have this afternoon, I would like to address a different aspect of health inequality—dementia. Dementia is a disease, but it is not primarily treated by the NHS. It is a Government commitment to provide NHS services free at the point of use. If someone has a stroke, heart problems, cancer or flu, the NHS will treat them free of charge. If someone has dementia, a recognised disease, it can cost tens of thousands of pounds—I learned today that it can cost up to £100,000—to get the care that they need.

I am suggesting that it would be in the interest of the Government, the Department of Health and Social Care and certainly those who are concerned about social care budgets to make dementia an NHS problem, rather than a problem for social care. According to the Alzheimer’s Society, which is about to launch a call for a fund for dementia, 50,000 avoidable hospital admissions happen simply because we do not adequately care for those with dementia or for those who care for them. Failing dementia care services could be avoided. According to independent reports, 23% of all services for dementia are failing. That sounds quite dramatic, and it is dramatic when one sits with a person who has cared for a loved one and who has also been in hospital because she cannot cope with being awake every night and trying to ensure that her husband does not turn on the stove, fall out of bed or fall down the stairs. Where we have failing services, because the issue is not properly dealt with within the NHS family, we really have problems and we cannot fully understand how severe the problems are.

It is a pleasure to serve under your chairmanship, Mr Hollobone.

I congratulate the hon. Member for Telford (Lucy Allan) on securing the debate. She was absolutely right to say that, as important as our NHS is in treating and caring for us when we get ill, reducing health inequalities —in my Oldham East and Saddleworth constituency, there is an 11-year life expectancy gap between rich and poor—goes beyond the NHS and the Government’s 10-year plan.

The term “health inequalities” refers to the increasing mortality and morbidity that occur with declining socioeconomic position. This is the systematic, socially reproduced, differential distribution of power in relation to income, wealth, knowledge, social status and connections. There is overwhelming evidence that those factors are the key determinants of health inequalities, influenced by written and unwritten rules and laws across our society. Those things, rather than biological and behavioural differences, drive these inequalities. No law of nature decrees that the children born to poor families should die at three times the rate of children born to rich families, but that is the reality in 21st-century Britain.

Given that those health inequalities are socially produced, they are not fixed or inevitable. If the Government were committed to tackling these burning injustices—let us face it, what could be more unjust than knowing you are going to die earlier because you are poor?—a starting point would be to tackle their regressive, unfair economic and social policies.

Countries that have a narrow gap between rich and poor have not only higher life expectancy rates, but better educational attainment, social mobility, trust between communities and so on. Fairer, more equal societies benefit everyone. Unfortunately, the concentration of power in tiny elites is happening more than ever in the UK.

Thank you for calling me, Mr Hollobone. I am pleased to be here this afternoon and that the hon. Member for Telford (Lucy Allan) has brought up this matter of health inequalities. She mentioned the Health Committee of the previous Session. I chaired the Health Committee under the last Labour Government, which looked into health inequalities and found that there are great difficulties in moving on from that.

In 2010, the Marmot review on health inequalities was published. Since then, we have had legislation. I was on the Committee for the Health and Social Care Act 2012. I was really pleased that health inequalities and population health was a big issue, and it was put in statute that those things needed addressing. I am sad to say that I have not heard a murmur from Ministers since then in relation to reducing health inequalities.

As my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) said, Sir Michael Marmot was a leader on this matter. He is now involved in the Institute of Health Equity, which, in September last year, released a fascinating publication. In conjunction with that publication, Sir Michael Marmot wrote on his blog about the complexity of health equalities, a point recognised by the hon. Member for Telford and my hon. Friend the Member for Oldham East and Saddleworth. Sir Michael Marmot wrote:

“There has been a contradiction at the heart of recommendations for action on health inequalities. No one is more concerned with health than those of us in the health sector. But the key determinants of health inequalities lie outside the health care system. It is not so much what doctors do, or don’t do, for patients that cause health inequalities, but the conditions in which people are born, grow, live, work and age.”

That is absolutely true. To be fair, the coalition Government tried to bring in legislation that would help people to recognise that, not only in the health service, but in the wider world.

Obviously, we are discussing the duty to reduce health inequalities, but as other hon. Member have mentioned, the increase in life expectancy is stalling and healthy life expectancy is falling. There is an exact linear correlation with deprivation. Women in poorer areas will have 26 years of poor health compared with 13 years for the least deprived. That all generates health pressures in the health service and in social care. Last year, the Scottish Government passed the Fairer Scotland Duty, which puts an obligation on all public bodies to work towards reducing inequality.

There are different aspects to this issue, including access to healthcare, which the hon. Member for Telford (Lucy Allan) talked about. In Scotland, we now spend £185 a head more on health and £113 a head more on social care than in England. That allows us to offer free personal care, which allows people the luxury of staying at home if they need the support mentioned by the hon. Member for St Ives (Derek Thomas).

A key issue of access to healthcare is free prescriptions. They are not available in England, other than for a very limited number of conditions, not including asthma. Asthma UK has conducted surveys showing that, at some point, half of all patients have not collected their prescription, and that three-quarters of asthma patients struggle to pay for their prescription. Of those who did not collect their prescriptions during that period, 13% were admitted to hospital. That is not cost effective.

The long-term plan talks about access to a digital GP, video access and healthy people being able to buy genomic testing. I am sorry, but all that will feed the inverse care law of increasing demand from the better-off instead of tackling unmet need among poorer people. Those are the people who do not attend appointments for screening, who live far away from services and who do not have access to decent healthcare.