Hello
I just received the following from Simon Stevens, chief policy advisor to
the SoS.
Adam
LONG-TERM MEDICAL CONDITIONS ALLIANCE CONFERENCE
ROYAL COLLEGE OF PHYSICIANS
28 FEBRUARY 2001
RT HON ALAN MILBURN MP
Breaking the link between poverty and ill health
This conference is timely for three reasons.
First, around one in three people in this country live with a long term
health condition. With reductions in mortality and with people living
longer, that figure is set to rise rather than fall over the course of the
next few years.
Second, there is increasing evidence to show that greater control by
patients over their own care - 'self-management' - benefits people living
with long-term conditions. It can bring both better quality of life and
fewer hospital admissions.
And yet third - health care in this country, as in most countries, still
tends to focus on acute problems at the expense of managing and indeed
preventing chronic illness.
So there is a pressing need for change.
I want to acknowledge the excellent work that the LMCA has undertaken to
improve our understanding of self-management over the last decade or so.
Having read the LILL report I know that the success of the LILL project,
building on the pioneering work of Arthritis Care, provides an excellent
foundation.
The essential ingredients for a new approach are now clear. First, for
people with long-term illness to be treated as individuals, not illnesses.
Second, for patients to have their expertise recognised. After all they are
the ones who know what it is like to live with the condition day in day out.
Third, a move towards a much greater partnership and shared decision-making
between the patient and the clinician. Fourth, a focus on prevention and
self management strategies to help avoid acute episodes. Fifth, a
recognition of the importance of quality of life. And finally access to high
quality information, including details of relevant patient organisations.
These seem to me to be the hallmarks of a genuinely patient-centred NHS.
The NHS Plan we published last year committed us to establishing a
comprehensive Expert Patients Programme and we will deliver that commitment.
Indeed I hope that before too long we will shortly be publishing the report
of the Expert Patients Taskforce setting out a major expansion of
patient-led self-management programmes.
We also need to mainstream this agenda across the NHS and social services
too. National Service Frameworks were introduced by this government to raise
quality and reduce unjustified variations in services.
Later this year we intend to publish the Diabetes National Service
Framework, the first to focus on a chronic disease. Encouraging people with
diabetes to play a full role in the management of their own condition is a
cornerstone of effective care. To do this, we need to give them the
knowledge and skills to become partners in their own care. When we publish
the diabetes NSF, it will put the person with diabetes at the centre of the
health care system. I also believe that it will be a model for how the NHS
supports and cares for people who are disadvantaged in some way - in this
case as a consequence of chronic disease.
Today I want to go beyond that. I can announce that we will develop an
additional new National Service Framework for Long Term Health Conditions.
To be drawn up in partnership with you, the organisations represented here
today, the NSF will have a particular focus on the needs of people with
neurological disease and brain and spinal injury. It will include services
for people with epilepsy, Multiple Sclerosis, Parkinson's Disease, motor
neurone disease and other similar conditions. The NSF will overcome some of
the lottery in care and ensure health and social services work more
effectively together in all parts of the country to provide the right level
of care and treatment for people with long term health conditions.
Those people are more often poor or live in the poorest parts of our
country. There is a particularly strong correlation as many of you here will
know between social class and long-term health conditions such as diabetes
and epilepsy; and a fundamental and consistent link between poverty and
ill-health. I believe government has a responsibility to attempt to break
that link.
For too long in my view the health debate in this country has been focussed
on the state of the nation's health service and not enough on the state of
the nation's health. Of course there is a relationship between the two.
The fact that we have such appallingly high levels of deaths from coronary
heart disease is in part linked to the poor provision of services to prevent
and treat one of the country's biggest killers. It is also true that
decades of neglect and under-investment have taken their toll on the
National Health Service and on the people who work in the service. Now
however we are in a different era. For years the NHS was in survival mode.
Now it is in expansion mode. Of course there are huge problems but there
are clear signs of progress too. 17,000 more nurses, almost 7,000 more
doctors, the first increase in hospital bed numbers for four decades,
shorter waiting lists and the fastest improving cancer and cardiac services
anywhere in Europe. Indeed the record extra levels of investment the
Government is putting in makes the NHS the fastest growing health service of
any major European country.
And investment can lever in reforms which will further improve health
services - to make care better and faster for patients. The real focus of
this programme of investment and reform now has to be where it should have
always been - on improvements in health.
The key questions today on health have to be about how best we can improve
the health of the population. How we can cut deaths from heart disease.
How we can improve cancer survival rates. How we can add years to life and
add life to years. And crucially how we can tackle the huge inequalities in
health which scar out nation.
Throughout this century life expectancy has improved. Indeed for men in
England - although not for women - our life expectancy today is ahead of the
European average. But for decades this general improvement has disguised a
widening gap between the health prospects of poorer people and people who
are better off.
Within months of coming to power in 1997 the Government asked Sir Donald
Acheson to conduct an independent inquiry into these health inequalities.
His report found that the country was divided - by area, by social class, by
gender and ethnicity, and worse, that many of these inequalities in health
status had been steadily increasing for 20 years. As a result, boys born
into the poorest families in the land today can expect to live almost a
decade less than boys born into the wealthiest families.
The biggest health improvement our country can make is to tackle this
unfairness. That seems to me to be the right thing to do on grounds of
fairness and justice. But it is right to do it on economic grounds too.
Economic success today depends on harnessing the skills and potential of all
of our people and not just some. Poor health like poor education blights
too many communities. It holds back too many people. The number of people
who are long term sick and disabled wanting a job but not presently working
has increased to almost a million over recent years. Many will suffer from
those chronic conditions that those of you here today represent.
This vicious cycle of ill health, unemployment and poverty is mutually
reinforcing. It costs the individual. It costs the health service. It
costs the taxpayer. It must now be broken.
Our task as a government is to ensure that there are genuine opportunities
for every section of society in every part of our country. Where we remove
the disadvantage that prevents people from realising their potential -
whether for reasons of chronic disease, social background, ethnicity or
location. Our vision is of a society where there are opportunities for all
and not just some. The chance to get on. The opportunity of a job. The
opportunity for education. To live in a community free from crime and the
fear of crime. The opportunity to enjoy better health too.
Our insight today is that a healthier nation calls for a fairer society. The
job of improving health then is a job not just for one department of
government but for the whole of government. Creating jobs, making work pay,
ending child poverty. These are policies that are fair and just. They make
good economic sense. They make good health sense too.
And in this first term we have made good progress. There is more investment
in poorer neighbourhoods. There are one million more jobs in the economy.
The minimum wage, the working families tax credit, the 10p starting rate of
income tax - all these are raising the living standards of millions of
poorer families.
The progress we have made in our first term allows us to set a new ambition
for any second term. To now undertake the biggest assault our country has
ever seen on health disadvantage. To start to break the link between
poverty and ill health. To improve life chances for all but to improve the
health of the poorest, fastest in our nation.
For years there has been a paralysing debate about whether the NHS could do
anything to tackle these health inequalities given their apparent
deep-rooted social and economic causes. Conversely some argued - even in
government - that it was the individual not society that was to blame for
ill health. Both analyses became a recipe for hopelessness and for
inaction. Today a new perspective is needed. An approach that accepts that
there are wider determinants of ill health - and that there is now a
wide-ranging programme of action to deal with them. But an approach that
also understands that the NHS can make a specific contribution to improving
the health prospects of the communities it serves.
It can do so in large part by re-focussing its efforts onto prevention as
well as treatment. Not the old-style health promotion policies of the past
seeking to cajole people into adopting healthier lifestyles but a new
approach that offers people the opportunity of better health. One that
recognises that people have the right to make a choice about what they eat
or whether they smoke. But that provides people with the opportunity to
have a healthier diet or to give up smoking if they so choose. Many have
not had that opportunity because healthy food has not been available locally
or because help to give up smoking has not been available freely.
In poorer communities the NHS now has a key role to play in providing
precisely those opportunities. By working in partnership with local people,
local government and local organisations the NHS can make a huge
contribution to narrowing health inequalities. And to focus the efforts of
the NHS we will now set for the first time ever clear national targets to
reduce those health inequalities.
I want to now set out to you what we will do and how we will do it.
Our first national target will be to reduce health inequality amongst
children. Health at the beginning of life is the foundation for health
throughout life. There is clear evidence from long-term studies that health
status in the first years of life can be tracked throughout life. There is a
clear gradient in infant mortality between social classes too.
We are the first government committed to the eradication of child poverty.
The measures we are taking are lifting 1 million children out of poverty.
Now we make a new commitment to help ensure every child has a fair start in
life.
So our first health inequality target is: to reduce the health gap between
children in different social classes. Starting with children under one year,
by 2010 we will reduce by at least 10 per cent the gap in infant mortality
between manual groups and the population as a whole. In setting this target,
we expect the national infant mortality rate to fall for the first time
below 5 deaths per thousand live births by 2006 and to result in
approximately 3000 children's lives being saved by 2010.
The wider action we are taking will help deliver these commitments. But
achieving this ambitious target will require more specific action too.
So we will extend Sure Start, a government-wide programme to increase
opportunities for disadvantaged young children, so that it reaches one third
of under 4s living in poverty by 2004.
There will be targeted help for pregnant women to give up smoking because of
its correlation with miscarriage, low birth weight and high levels of
perinatal death.
We will also build on the very real reductions that have taken place in the
incidence of cot death over recent years. Babies from the most disadvantaged
social groups have a higher death rate from Sudden Infant Death Syndrome
compared to babies from more advantaged backgrounds. One of the ways we hope
to support mothers from disadvantaged backgrounds is by extending postnatal
care by midwives to help improve rates of breastfeeding and early detection
of postnatal depression since both can have a profound effect on the future
of the child.
There will be more support for parents by training more nurses, midwives and
health visitors. There will be increased investment in neonatal intensive
care provision. And underpinning this national crusade to improve children's
health - for example to tackle childhood illnesses like asthma - there will
be a new National Service Framework setting in place new national standards
for children's services.
As a result of these actions - and the government's wider programme to end
child poverty - our ambition now can be to give every child the best
possible start in life.
These initiatives will improve health, narrow inequalities and save
thousands of lives. Many of them will be focussed on areas where
deprivation is highest and health is poorest.
There must be specific action to reduce wider health inequalities in these
geographical areas too. So today, I can announce our second national health
inequality target: to reduce the difference in life expectancy between areas
with the lowest life expectancy and the national average. Starting with
Health Authorities, by 2010 we will reduce by at least 10% the gap between
the fifth of areas with the lowest life expectancy at birth and the
population as a whole.
Again our wider government programme will make a difference. But it too
will need to be complemented by more specific action. This will take five
forms.
First: action on cancer and coronary heart disease - our country's biggest
killers and indeed major causes of chronic illness and disability. Better
outcomes here will make the biggest contribution to improvements on overall
life expectancy. Since both killer diseases have such strong social class
gradients a concerted effort to reduce preventable deaths among the most
disadvantaged in the community will help us realise our new target. Both
cardiac and cancer treatment services are now benefiting from substantial
new investment and far-reaching reforms. Through new investment we are
seeking for example to overcome the appalling problem where those areas with
the highest incidence of coronary heart disease often have the lowest levels
of cardiac surgery. But it is in prevention that the biggest gains can be
made.
So, second: we will take more action to tackle smoking, the principal
avoidable cause of death in this country. It kills 120,000 people and costs
the NHS up to £1.8 billion a year.
Smoking is the principal cause of the inequalities in death rates between
rich and poor. Put simply, smoking is a public health disaster.
We have committed ourselves to reducing smoking amongst all adults and to
bring about an even bigger reduction in smoking amongst adults in manual
socio-economic groups. We will do this through a £50 million public
education campaign and through more direct action still to help the 70% of
smokers who say they want to give up.
By the end of March this year we will have in place the most comprehensive
smoking cessation service anywhere in the world - available everywhere in
our country. Health authorities will be targeting those groups with the
highest smoking rates with the aim of helping at least 1.5 million smokers
to give up during the course of this decade. Together with our efforts to
ban tobacco advertising - in particular to protect children - these
initiatives will both reduce the terrible toll of smoking related disease
and contribute to a major reduction in inequalities in health
Third: we will take action to improve diet. Sir Donald Acheson's report
identified differences in nutrition as a fundamental determinant of health
inequalities. Eating at least 5 portions of fruit and vegetables a day could
reduce deaths from coronary heart disease and cancer by 20%.
People make their own choices about what to eat. That is right of course.
The role of government is to ensure people have the information they need to
choose to eat healthier food and the ability to exercise that choice
wherever they live.
So we are working closely with food retailers to increase access to fruit
and vegetables in deprived areas - targeting communities poorly served by
food retailers at present. And today we take another important step.
Last year's National Diet and Nutrition Survey found that one in five
children were eating no fruit at all in a week. Children in low income
groups are 50% less likely to eat fruit and vegetables than those in the
highest income groups. Yet we know that eating fruit and vegetables is not
only an important source of nutrients for children. It also reduces the
risk of disease in later life.
From today 80,000 children across England will receive a free piece of fruit
each day at school as part of the Government's drive to improve child
health. It is an approach that has been piloted in a few dozen schools.
From today it will be extended to more than 500 schools. Many will be in
poorer areas. For some children it will double their intake of fruit.
Our intention is that by 2004 every child in nursery and every child aged
four to six in infant schools will be entitled to a free piece of fruit each
school day. This will be the biggest programme to support child nutrition
since the introduction of free school milk in 1946.
Fourth there will be new screening programmes to reduce the risk of disease.
The breast screening programme will be extended to women aged 65-70, with
400,000 more women being screened every year.
We are currently testing the feasibility and public acceptability of a
national colorectal cancer screening programme.
By 2004 there will be effective and appropriate screening programmes for
women and children including a new national linked antenatal and neonatal
screening programme for illnesses such as sickle cell disease.
Fifth: there will be extra health resources in areas of greatest health
need. As a start we have allocated, for the next financial year, £130
million to the 50 or so health authorities where years of life lost are
highest. By 2003/4 we will have introduced a new funding formula for
distributing NHS resources across the country. Its driving force will be an
assessment of the health needs of different communities. Reducing
inequalities will be a key criterion for allocating NHS resources under the
new formula.
In the meantime we are pressing ahead with developing more primary care
services in deprived areas principally through the new PMS contract and more
salaried GPs.
Today I can announce a further new investment in primary care. The NHS Plan
committed us to improve 3,000 primary care premises to make them fit for
purpose through a new joint venture with the private sector - NHS LIFT.
Newcastle, Manchester, Salford & Trafford, Sandwell, Barnsley, Camden &
Islington and East London all urgently need better primary care facilities.
They are all areas of high health need. It is right that these will be the
first six areas for extra investment through NHS LIFT.
They will not be the only areas to benefit. There will be more investment
to come in the course of the next few years. There is much, much more to be
done to give people the health services they need. But we now must move on
from concentrating solely on our National Health Service and concentrate now
on our national health - on health outcomes and standards rather than just
inputs and structures.
That will mean a continued emphasis on getting waiting times down because
faster care does mean better health. It also means a constant effort to
ensure we have the staff, beds and equipment we need to improve care for
patients.
But it means too a new premium on prevention and tackling health
inequalities.
Today I have been able to announce a major programme to improve health
chances. A new blueprint for services for people with long term health
conditions. New targets to reduce health inequalities. New action to enable
them to be achieved.
The health inequalities which scar our nation are real life not a sound-bite
or a slogan. They are concentrated in the poorest parts of our country; they
are deepest amongst the poorest people in our country. They represent the
most fundamental challenge to the opportunity society we seek to build.
What greater constraint on opportunity for all than long-term limiting
illness for many and shortened lives for some?
What greater affront to those of us who do believe in One Nation than the
idea that many of our fellow citizens should be more likely to die early
simply because of their social background?
And what bigger tragedy for our country than infant mortality rates in some
parts of England three times higher than elsewhere in England?
The choice for government is clear and a choice for the country too. We can
regret these facts and wring our hands, as governments have done for a
generation. We can hope the benefits of free-market economics trickle down
in time to the poorest people and the poorest parts of our country.
Or we can learn the lessons of history. We can recognise that trickle down
economics has failed too many families and too many communities. We can
then redouble our efforts to tackle these health inequalities by improving
the health of our nation overall and deliberately and determinedly raising
the health of the poorest, fastest.
That is the choice we have made. I believe it is the right choice for our
country.
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