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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.