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Health: Women and Low-income Groups

Volume 753: debated on Thursday 20 March 2014

Question for Short Debate

Asked by

To ask Her Majesty’s Government what steps they are taking to reduce inequalities in health affecting women and low-income groups.

My Lords, I am delighted to have the opportunity to introduce today’s debate. I am also delighted that the subject has attracted such expert speakers and I very much look forward to hearing your Lordships’ contributions.

There have been three key reports on inequalities in health: the Black report back in 1980; the Acheson report in 1998; and, more recently, the Marmot review in 2010. Clearly, health is a key part of social mobility and, although the population has access to the NHS, there is a huge inconsistency in the problems faced by low-income and high-income groups, between men and women, and across ethnic groups. It is often said in international development circles that health is a human right. It is critical to income growth and poverty eradication. That applies just as much in inner-city Birmingham as it does in rural India. Health underpins access to employment, education, engagement with economic activity and quality of life. Low-income groups often report barriers to accessing health services, which drives poor health outcomes. Although life expectancy is going up, so too, unfortunately, is the gap between the rich and poor. The distribution of health and disabling health conditions across the population of England has been shown to follow a sizeable, persistent and incremental pattern: health outcomes generally worsen in line with greater levels of socioeconomic disadvantage.

An analysis by the Equality Trust has found that in the past 20 years alone, the gap in life expectancy for those in different local authority areas has increased by 41% for men and a staggering 73% for women. For example, there is now an 18-year difference in healthy life expectancy between women living in Richmond, where it is 72 years, and Tower Hamlets, where it is 54 years. This has real policy implications for fair and reasonable pensionable ages. Evidence also shows that women suffer more from poverty, gender inequality, gender-based violence and mental health problems.

Investment decisions based on women’s specific health needs are a practical and cost-effective way of delivering the NHS social inclusion agenda. For example, the cost to the NHS of violence against women and girls is estimated to be around £1.2 billion a year. Domestic abuse alone costs a further £176 million a year in mental health services. The return on investment in prevention is therefore significant. I would welcome the Minister supporting investment in the scale-up of dedicated outreach services for marginalised, low-income and hard-to-reach populations in the UK. Charities such as Find and Treat are excellent examples of organisations providing such services.

Reducing health inequalities is one of the NHS’s top five priorities, and rightly so. I welcome health organisations now having a statutory duty to have regard to the need to reduce health inequalities, and congratulate the Government on this. Therefore, health improvement is no longer the only success criterion; reducing differences in health between populations is also a welcome policy objective for NHS England and Public Health England. Not only does economic inequality affect health, but more unequal societies are more likely to experience poorer literacy rates, higher incidence of drug addiction and greater exposure to diseases.

Due to time constraints, I shall briefly touch on three issues: coronary heart disease, drugs and TB. I turn first to coronary heart disease. Collectively, as we know, heart and circulatory diseases cause more than a quarter of all deaths in the UK. Rates of premature death have been declining since the 1970s but this decline has not been reflected equally in all parts of our society. Tackling inequalities in heart disease should be hard-wired into the performance measures of the NHS and explicitly reflected in the quality and outcomes framework and the payment-by-results scheme for GPs, and should highlight gender differences in risk factors, screening and treatment needs. There is not sufficient evidence that this is being done.

Secondly, 1.2 million people are affected by drug addiction in their families, mostly in poor communities. The annual cost to society of drug addiction is £15.4 billion and this does not take into account the huge cost to families and end-users in their personal lives. An estimated 250,000 to 350,000 children who are affected by parental substance abuse face additional risk and harm, including neglect, being taken into care, involvement in drug abuse and poor mental health. Drug prevention can therefore be a mechanism for reducing inequalities and social exclusion. Drug treatment is an essential part of a successful drug policy and of reducing inequalities. However, evidence from the recent European Quality Audit of Opioid Treatment suggests that NICE and Department of Health guidance is not being fully implemented. The survey found that, although patients are ill informed of their treatment options, choice of treatment is often driven by patients. The UK has the second highest reported rate of patient relapse. Anecdotal evidence suggests that many patients may be relapsing and then re-entering the same treatment. Can the Minister say how the Department of Health and NICE guidelines are being implemented and evaluated, and whether that information is being disseminated to clinical commissioning groups?

My third and last area of health inequality is TB, which is a global disease of poverty. TB has killed more people than any other infectious disease in history. It remains the second deadliest infectious disease in the world, claiming 1.3 million lives each year. TB is airborne and infectious; in a world of globalised travel, it is no surprise that nearly every country in the world has TB. London has the highest rates of any capital city in western Europe. In 2012 there were nearly 9,000 cases of TB, nearly 10% of which came from just three London boroughs: Newham, Brent and Ealing. The first two of these are the London boroughs with the worst rates of overcrowded and temporary accommodation. This is not a coincidence. Although the number of cases has stabilised, rates in Indian, Pakistani and Bangladeshi communities are steadily rising. This is not a coincidence either. These groups are often marginalised and report barriers to accessing healthcare. TB in the UK is far from being under control and health inequalities are driving it forward.

Many poor people around the world suffer and die because they cannot afford to buy advanced medicines that are still under patent and often sold at a 50-fold, or even a 100-fold, mark-up. The NHS spends an estimated £8 billion every year on patented drugs. There are merits in other ways of incentivising important pharmaceutical innovations, such as a health impact fund, which Germany is actively considering. Would the Minister consider meeting the architects of the fund to see what benefits the UK could derive from it?

I end with five key points. First, it is time for action. How are the Government implementing the recommendations of the Marmot review? Secondly, there should be a joint narrative between the Department of Health, NHS England and Public Health England on what they are doing together to tackle inequalities and who is accountable for what. Like the King’s Fund, I believe that local authorities have a critical role to play, through their new public health duties, but the reduction in health inequalities cannot be delivered solely by them. Thirdly, Public Health England should show leadership and visibility by showing how it is supporting and, where necessary, challenging other government departments. Fourthly, all new government policies and services should be subject to health equality impact assessments, requiring policymakers and service providers explicitly to take health inequalities into account. Finally, I totally agree with the British Heart Foundation when it states that each of the four Governments in the UK should appoint a senior Minister with cross-cutting responsibility for tackling health inequalities and each government department should have an objective to reduce health and social inequalities.

My Lords, the noble Baroness, Lady Manzoor, has given us the opportunity to cover a very wide canvas this afternoon on an issue that is so deeply rooted in deprivation and its results that it is difficult to do it justice in the course of an hour. I fear that I shall make the problem even greater by dealing predominantly not with inequalities in the UK but with those across the world, because some of the most stark and striking inequalities in health, particularly women’s health, occur globally. I should perhaps reassure the Minister that I will not expect a fully fledged, all-singing, all-dancing DfID response from her today. However, I would be grateful if she could pass on these comments to colleagues.

Whichever society one is dealing with and wherever in the world, ill health is both the outcome of deprivation—social, economic and educational—and itself a cause of deprivation. At its most stark, it is illustrated in life expectancy: there are those figures that the noble Baroness gave us of a healthy life expectancy for a woman in the UK varying from 54.1 years in Tower Hamlets to 72.1 years in Richmond-upon-Thames. There is a great deal to discuss but I shall concentrate on women’s health and those areas specific to women, pregnancy and childbirth, where men do not risk morbidity and mortality at all. We should remember that gender-specific risk starts early. For some, it starts with selective infanticide, while there is female genital mutilation and child marriage, which is not just a social ill but a health threat as well. A girl who gives birth while aged under 15 is five times more likely to die than one who is over 15, and so are her babies.

I should declare some interests. My international development interests are as in the register but, particularly, I am chair of the external advisory group at the Centre for Maternal and Newborn Health at Liverpool School of Tropical Medicine and, in the UK, a member of the General Medical Council. I am also grateful to Professor Gwyneth Lewis of the UCL Institute for Women’s Health, who has done so much work on maternal mortality in this country and abroad.

Maternal death rates illustrate the inequalities that exist in world health and between women all over the world today. In 2010—I think all my figures are from that year—287,000 women died in childbirth. One woman dies in childbirth every two minutes across the world. In the UK, where the maternal mortality rate of deaths per 100,000 is 11, every one of those deaths would be subject to a confidential maternal death inquiry. In sub-Saharan Africa, where the MMR is 500 deaths in every 100,000, that inquiry would be considered completely inappropriate and impossible to carry out. Many of those deaths may not even be officially recorded. The lifetime risk of dying in pregnancy is one in 20,000 in the United Kingdom; in Sierra Leone, it is one in seven.

Of course, these deaths are not the only consequence. For every woman who dies, perhaps 15 suffer morbidity. Neonatal rates are absolutely related to maternal deaths and yet perhaps 80% of maternal and perinatal deaths are preventable. It was said by Mahmoud Fathalla in 1988:

“Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving”.

We can see in our international development programme that there are programmes that work, that are sustainable and that bring skilled birth attendance—perhaps the single thing that makes the difference to maternal mortality. Across countries in Africa, the Making It Happen programme, led by Nynke Van den Broek of Liverpool, is providing sustainable training and support for the maternity services so that they can improve their death rates. I very much hope that in the response to come from DfID we will get continuing commitment to such programmes.

Returning to this country, where we have one of the lowest death rates in the world, considering how good our recording is, poverty and deprivation still make it more dangerous to give birth in this country if you are from a lower social class or have less education. The statistic that stands out to me is that women, single or in partnership, in a family with no wage income are 10 times more likely to die or suffer complications in childbirth—10 times. The link between poverty and health continues in this country, as it does between countries.

My Lords, I thank the noble Baroness, Lady Manzoor, for introducing this debate on this challenging issue. We know from the NHS, the Office for National Statistics and elsewhere that poorer people live shorter lives and that they live more of their lives with limiting illnesses. The Marmot review in 2010 highlighted the seven-year gap in life expectancy and the 17-year gap in disability-free life expectancy between those on the lowest incomes and those on the highest.

We also know that there is a significant difference in rate of diagnosis, treatment and outcomes for the five biggest killers depending on where you live. Last month, the ONS published its analysis of the health deprivation divide using the 2011 census and found that men and women aged 40 to 44 living in the most deprived areas are about four times more likely to have “not good” health compared to their equivalent in the least deprived areas.

In terms of gender, the most recent ONS figures, published at the weekend, show that women in the most advantaged areas can expect to live 20 years longer in good health than those in the least advantaged areas. Poor women spend only 66% of their lives in good health, compared to 83% of the richest. The richest women live nearly seven years longer than the poorest. Although women have historically enjoyed longer life expectancy and more prolonged health than men, that gender advantage is almost entirely eroded by social inequalities.

The Marmot review, Fair Society, Healthy Lives, made the simple point that reducing health inequalities is a matter of fairness and social justice, but tackling those inequalities and injustices is neither simple nor straightforward. Health inequalities result from social inequalities, so any action on health inequalities requires action across all the social determinants of health.

The Marmot review’s first and highest priority for action was giving every child the best start in life. I have spoken on this before, but it is a subject that I feel very strongly about. The evidence is overwhelming that investing in the pre-school years pays most dividends for health and well-being in later life. What happens during early years, starting even in the womb, has lifelong effects on everything from obesity, heart disease and mental health to educational achievement and economic status. That is why it is so important that we provide more parenting support programmes and that we have a well-trained early years workforce and high-quality early years care.

I will not dwell on that point but want instead to look at where we are four years on from the Marmot review. The Health and Social Care Act 2012 places a duty on the Secretary of State, NHS England and clinical commissioning groups to have due regard to reducing inequalities, and there have been some successes. The widespread adoption of high-impact interventions, such as prescribing cholesterol-reducing drugs and drugs to control blood pressure, and increases in stop-smoking services, have all shown an impact.

However, this sort of success has been uneven. A King’s Fund report tells us that the overall proportion of the population that engages in three or four of the four main areas of unhealthy behaviour has declined significantly, from around 33% of the population in 2003 to around 25% by 2008. However, people with no qualifications were more than five times as likely as those with higher education to engage in all four poor behaviours in 2008, compared with being only three times as likely in 2003.

So far, policy has focused on tackling individual lifestyle risks one at a time but this ignores the distribution of these behaviours. We need a more holistic approach to policy and practice that addresses the lifestyles of people showing multiple unhealthy behaviours. When your future prospects look hopeless and your life is lonely and miserable, there is little reason to make changes to your behaviour now in order to add years later. Will the Minister tell us what is being done to ensure a more integrated approach to behaviour change, which links to inequalities policy and focuses more directly on the Government’s stated goal to,

“improve the health of the poorest, fastest”?

Michael Marmot recently returned to the fray: last month he alerted us that the ONS plans to reduce the amount of data it collects which highlight the differences within local authority areas. My borough of Kensington and Chelsea has the highest average life expectancy in the country but there are pockets of extreme deprivation. One ward has a life expectancy of 71 years, whereas it is 92 in Knightsbridge. These are the data that should inform the commissioning of services. I hope that the Minister can reassure the House that these data will continue to be collected.

I welcome the recent launch by Public Health England of a national conversation on health inequalities. However, this conversation needs to take place at rather a higher volume than it appears to have done so far. Like the noble Baroness, Lady Manzoor, I ask the Minister what the Department of Health, NHS England and Public Health England are doing together to tackle inequalities. They need to be heard telling us how they will use their powers, not just calling the rest of us to action. We need a joint commitment. As NHS England is now the monopoly buyer of primary care, it needs to use that power to reduce health inequalities. Public Health England should share its expertise in health impact assessment with other departments so that they are able to take into account the health inequalities impacts of one potential decision versus another.

The task of reducing health inequalities cannot be left to local authorities to deliver solely through their new public health duties. We need to ensure that local authorities invest money and expertise to ensure long-term reductions in health inequalities. One of the values at the heart of the NHS constitution is that “everyone counts”. Our resources must be maximised for the benefit of the whole community and we must make sure that nobody is left behind.

My Lords, I thank my noble friend Lady Manzoor for instigating this debate. It is a hugely important subject. I will concentrate most of my remarks on the growing problem of TB and, in particular, drug-resistant TB.

Overcrowding is perhaps the biggest risk factor for the transmission of TB. Anyone who has TB and is not treated will remain infectious, potentially passing the disease on to those who live with them. For those in temporary accommodation, TB is a threat to keeping their accommodation. TB is infectious and difficult to treat, and patients are often scared of losing their accommodation if they admit to having TB.

People with lower incomes are statistically more likely to experience drug or alcohol abuse problems, which reduce their immune response and heighten their risk of contracting TB and other infectious diseases. Cases in the UK are centred around big cities. London has an average rate of 42 cases per 100,000. As my noble friend Lady Manzoor has already remarked, two of the boroughs with the most severe problems with overcrowding and temporary accommodation, Brent and Newham, are also those with the highest rates of TB in the UK.

The problem becomes even more severe among the homeless population. The disease attacks people with reduced immune systems, so the impact of rough sleeping, poor nutrition and other factors associated with the chaotic lifestyles of the homeless can increase their chances of developing TB in the first place. In addition, the homeless community is less likely to present to primary healthcare when experiencing symptoms of TB or any other disease. That increases their likelihood of remaining infectious and transmitting the disease to others. It also increases the likelihood of them developing more severe and difficult-to-treat symptoms, due to the opportunity for the disease to progress further.

Homelessness was also found to increase the likelihood of developing drug-resistant strains of TB, including a much greater risk of developing multi-drug-resistant TB. It was also found that homeless people are a dozen times more likely not to adhere to treatment, which puts them at even greater risk of developing, and transmitting, infectious TB.

The central thread running through all this is a critical problem with housing. Once admitted, hospitals cannot discharge people without a home address. If the disease is not advanced and they have no other health complications, most patients will not be admitted. TB treatment is extremely long: the average treatment duration is 220 days and the average cost of a bed per night is £500. A patient who cannot be discharged can cost the NHS £110,000 in bed fees alone. Specialist hostel accommodation is available and needs supporting. One project that I visited just two weeks ago in Euston costs £60 to £80 a day, including all food, a room, training, language skills and social support for TB treatment.

Does my noble friend the Minister agree that a holistic package of care, if widely adopted by the NHS in high-risk TB areas, could save taxpayers millions and greatly improve treatment outcomes, as well as reduce the spread of the disease?

My Lords, I, too, congratulate the noble Baroness on securing this debate, and on the excellent way in which she laid out the issues at the beginning. These are important themes, which go beyond health and beyond the UK. I will not talk about international development, although I will say in passing that I identify completely with everything my noble friend Lady Hayman said on that issue.

I was interested to note recently that the European Strategy and Policy Analysis System, which advises all the parts of the European Union, has identified inequality as the most significant long-term challenge now facing Europe. As recovery is now under-way, there is what it describes as a “trend break” in inclusive growth; in other words, growth that is taking everyone with us. It is interesting that in our international development world we talk about no one being left behind in health, but we are not doing very well at that ourselves.

That report goes on to talk about the most vulnerable, the growth in unemployed youth and the so-called lost generation, and the impact on the most vulnerable and the ill of the reduction of public services, all of it indicating that we are building up health problems for ourselves for the future.

That theme of inequality is one that we will have to keep coming back to, and it is important that we do so. I absolutely agree with the noble Baroness, Lady Warwick, that we need to increase the volume. Not only does the Department of Health need to do that, but we all need to keep pressing the points that I suspect we all understand very well, and make sure that they are turned into reality.

We in the UK understand those issues better than most. We have had a great tradition of research into and evidence of the relationship between health and income since the Whitehall study, which was begun in 1967. It shows the clear relationship between them; within that, it also notes that while women have longer life expectancy, as we have already heard, low income can affect them worse, and that there is a greater discrepancy in the length of healthy lives. Therefore in a quarter of the boroughs in the UK, men have longer healthy life expectancy than women do. We also know that people from black and minority ethnic communities are particularly affected, because they are overrepresented in low-income groups and face some specific health threats. Therefore we know what the problem is.

The relationship between health and income is complex, and has at least four components, all of which have to be addressed. The first component is simply the material one: whether people are able to buy better health with better food, gym membership and so on. Then there is the psychosocial: we now know the biological mechanisms that show the way in which stress impacts on the body and affects health. We also know that there are links between people in low-income groups and risky life behaviours, as we have already heard from a number of noble Lords. The reverse is also true: poor health can cause low income and reinforce the whole cycle. All these issues affect women, but for women there is a double impact, because many of them are carers or involved in bringing up children, and the health of women affects other people profoundly.

The way to deal with this is equally complex. The WHO study on social determinants, already referred to, stressed the importance of taking a life-course approach to health inequalities, with interventions at every stage from birth to old age, while the study from Europe that I mentioned emphasised investing in citizens and having a focus on promoting well-being.

We have in this country many good specific examples, of which I will name just one: in Lewisham, where they are targeting women’s inequality and picking up across the entire borough the sort of issues that I am talking of. But we need strategic impact, as the noble Baroness, Lady Manzoor, said; she described it in relation to coronary heart disease, drugs and TB. We need a much more strategic and followed-through approach at a higher volume than is the case at the moment.

I would be very interested to hear the Minister’s response to the noble Baroness’s questions. I suspect that she will tell us that the ideas outlined here and in what other people have said are central to the Government’s policies. However, I hope that she will not just spell out the Government’s hopes for their policies but point to particular examples where those policies are in reality reducing inequalities and having a positive impact on health. We all understand that there needs to be a cross-government approach; health by itself cannot achieve many of the things that we are talking about. Could the Minister also therefore give us good examples of where this approach is happening; for example, where education is working with health to develop health literacy among children?

Finally, the reverse of this is also true: some government policies from other departments may have adverse effects on equality and on health. Can the Minister therefore tell us what the health department is doing to assess the impact of policy from other departments on health and reassure us that the Department of Health can intervene, and indeed has intervened, where there is a potentially negative impact?

My Lords, I, too, thank the noble Baroness, Lady Manzoor, for giving us this opportunity to express our views, which is very welcome. I turned 80 last month and I feel that I am on the last lap of life. I have only one passion, which is for poor women, mainly in Africa and India, who get forgotten. There are 1 billion women altogether in Africa and India and what their lives are like we cannot even imagine unless we have gone there and seen it for ourselves. I am not going to talk about that, because it is a huge subject and I have views on what we can do about it, but I just want to tell your Lordships one little story.

I have a Nigerian friend who is from a village in the middle of Nigeria. She said to me that when a woman in her village reaches the age of 40, they have a street party. It is a great thing to reach the age of 40. What does that make us feel? I shall give another, recent example. I had an Indian maid. She does not work for me any more, but she comes to me. She says that I am her mother. I keep telling her that she is not my daughter, but it does not seem to have any effect. She came to me in a terrible worry about some medication that she had been given for her blood pressure. She said, “Oh, it’s not the same as what I had before. I don’t know what they’ve given me. What is it going to do to me?”. So I just read the leaflet. It was blood pressure medication. It was not the same packaging—there are so many different ones.

I want first to say, therefore, that I am much more concerned with ethnic minority women. Secondly, I want to mention a big problem, which is ignorance. Obviously, not everything is available to everyone—we know that—but unfortunately we are not doing anything about improving the awareness and understanding of what is available. A lot of ethnic minority women do not know what is available. They do not understand it. What they can have has not been explained to them.

A report for the All-Party Parliamentary Group on Sexual and Reproductive Health in the UK, launched in 2012, showed the differences in the availability of help in different boroughs of London. The differences were huge. Every woman has the right to have access to family planning, not only for herself—because it affects her health, her thinking and her feelings—but for the children she produces. If you have too many children, you cannot give them the attention they need.

We also do not do anything in schools. We are ambivalent about sex education. We do not teach our children what they need to know about their own bodies and needs. People say, “Oh, they will become more promiscuous”. Well, they will be promiscuous if they want to be promiscuous, whether we teach them or not. Maybe they will be more careful; maybe they will use condoms. Let us do that; let us work towards trying to bring in proper sex education in this country, because that will help the next generation.

We have heard about TB and things like that. There should really be a testing process before people come here. Most countries have testing processes for illness. If you know that somebody has TB, you can still let them come but then you give them treatment right away. You do not wait for them to spread the TB around to other people.

The other thing that is specific to ethnic minority women is depression. They suffer hugely from depression. There was a Chinese Peer called Lord Chan who set up a group, of which I was a member, to look at suicides among ethnic minority women. We have the need for family planning. We have mental health problems in minority groups. People are not trained well enough to manage the bicultural aspect. We need to be aware of that. It is very difficult to treat somebody with mental health problems via an interpreter.

There are so many issues. The noble Baroness, Lady Hayman, quoted Dr Fathalla. Actually, it was in the 1970s, earlier than she said, that he said that we do not treat women—not because we cannot but because we do not think they are worth treating. He was saying how bad it was; he was not saying it for himself. It is true. If you go to African countries, women’s health is right down the agenda. Nobody cares.

FGM was mentioned. Do noble Lords know that if a girl has been cut, the family gets more money for her? We should bear that in mind because quite often some of these ills are perpetrated for financial reasons; child marriage as well—they sell the girl. I said to my friend from Nigeria, “Two goats will buy you a girl of 12”. She said, “No, one goat”. This is the kind of world we are living in and this is the kind of treatment women are getting, so let us not do it here.

My Lords, following on from the noble Baroness, it is my fervent hope that before I die PSHE will be a core part of the curriculum in every school in this country. That is what we must fight for. I add my thanks to the noble Baroness, Lady Manzoor, for enabling us to have this important and wide-ranging debate. The speeches have given us terrific—and horrific—facts and figures, and much food for thought.

Like other noble Lords, I woke on Monday morning to read articles about the report from Oxfam, A Tale of Two Britains, which showed that the richest five families are worth more than the poorest 20% of people in this country—that is, 12.6 million people, almost the same as the number who live below the poverty line. These figures are deeply shocking and proof of the profound inequalities in our society. The report also said that, for the first time, more working households were in poverty than non-working ones and predicted that the number of children living below the poverty line could increase by 800,000 by 2020.

We know that there is a direct correlation between health inequalities and poverty. Many of the solutions to health inequalities lie outside the health sector—for example, with housing, good employment and security. As in so many areas, it is women who suffer most from health inequalities, not just personally but because they have responsibility for the health of children, partners and elderly parents. The Joseph Rowntree Foundation comments:

“Health and poverty are intertwined—being trapped in poverty piles on stress that perpetuates the cycle and worsens health further”.

I know that the Government will say they have taken action in the Budget to reduce poverty, but it is the reality for millions of people in this country. Next month, when last year’s Budget adjustments are made, they will still be living in poverty while millionaires are thousands of pounds better off.

Housing has a huge influence over people’s health: temporary accommodation; overcrowded rooms; damp walls; inadequate cooking facilities in B&B accommodation; cold homes because there is not enough money for the meter; and the stresses and strains of struggling to pay exorbitant rents. The Government will also say that they are taking steps to make affordable housing more accessible with schemes such as Help to Buy. Those schemes may well help some people and I am glad, but they do nothing to help people who are desperate to rent affordable homes, either from the public or the private sector; they merely create the potential for a housing bubble.

I am sure that we all agree with the conclusions of Sir Michael Marmot’s review on health inequalities, one of which is to ensure a healthy standard of living for all. Yet obesity is the plague of our era, first because of lack of activity and secondly because of poor diet: 26% of adults and 30% of children are classified as obese, the fourth highest level in the world. In a terrific debate last night on the report of the Olympic and Paralympic Legacy Committee, speaker after speaker spoke with concern about the need for greater emphasis on PE in the school day and how high-quality PE and sports programmes can boost school attendance, challenge anti-social behaviour, improve academic performance and, of course, make children healthier now and improve their future health. What are the Government going to do about this issue, which is inextricably linked to health inequalities? Last year, the National Children’s Bureau found that children living in deprived areas are nine times less likely than those living in affluent areas to have access to green space and places to play and to live in environments with better air quality.

Alongside exercise, a healthy and balanced diet is also essential but, given that Britain has some of the highest and most volatile food prices in western Europe, this is becoming harder and harder for people struggling with the squeeze on their household budget. Poverty means that, even though parents might know that fresh food is healthier than processed food, tinned and frozen food is often cheaper and, if you live in a B&B with a single gas ring or you are simply exhausted because of the stresses and strains of life, fast food looks like the only option. The health of many women often suffers because they regularly deprive themselves of food when the choice is between feeding themselves or their children. Yes, they can resort to food banks but only on three occasions can they suffer that indignity. I was extremely disappointed by the complacent and patronising response from the Government at Question Time today. It demonstrated a complete lack of understanding of the realities of life for so many people. My noble friend Lady Whitaker, who is in her place, said that since food banks got going at their present scale hospital admissions for malnutrition have increased by 74%. In answer, the Minister said,

“we are working with business and others to encourage people to adopt a healthier diet”.

That is not the appropriate answer. It demonstrated no grasp at all and a total lack of empathy, as did the continued emphasis on charitable giving. I celebrate the work of charities; food banks do a fantastic job, but I abhor the poverty that drives people to them.

On Tuesday, I had the privilege of spending a few hours with a young woman whom I first met when she was an inmate in HMP Eastwood Park. Thanks to her own resilience and work in the soap enterprise in the prison, of which I am the proud patron, she has turned her life around and is now in employment and caring for her children. We talked about inequalities and the problems that lead to women’s imprisonment, as well as their health problems, specifically mental health problems. The figures are stark: 70% of female sentenced prisoners suffer from two or more mental health disorders, yet, as in the general population, there is no parity between mental and physical health care. She suggested that, in order to help the women avoid problems following sentencing and to reduce consequential costs, every woman should have a mental health assessment before beginning her sentence. This seems an excellent idea and I would be grateful if I could discuss it further with the Minister together with Maria Thomas of the Shaw Trust, who has done a lot of work on this. I look forward to the responses from the Minister to the excellent questions raised today.

My Lords, I, too, am grateful to my noble friend Lady Manzoor for initiating this important debate. I thank all noble Lords for their excellent and informed contributions. I agree with the noble Lord who said that an hour is just not enough to do justice to the huge canvas of inequalities that there are not only in the UK but across the world. I regret, too, that in the time available I will not be able to answer all queries from noble Lords. I promise to write to all who have taken part in this debate to answer their queries and, I hope, to make them feel more reassured.

Health inequalities are a priority that is shared by this Government and Health Ministers across the whole UK. Worldwide, concern is high on DfID’s agenda and it has been very busy over the past few years implementing millennium development goals and thinking about what should follow on from them, particularly those areas surrounding women and children. For too long, health inequalities have denied many children a good start in life, prevented people realising their full potential and weakened communities. They are deeply rooted and a scourge on society, which is unacceptable. However, the tragedy is that, for the most part, they are avoidable. As the Secretary of State has said, we want to make them a thing of the past.

Health inequalities and the poor health outcomes that result are a focus for the health system, working with Public Health England and NHS England, and backed by new health inequalities duties under the Health and Social Care Act 2012. The Department of Health is ensuring that these bodies work together to overcome these inequalities. However, I have to give a warning that successes in any of these areas are not overnight. We have to be in this for the long haul, which is why strategy is so important. These organisations are barely a year old.

Our strategic approach is underpinned by the evidence in the Marmot review. The noble Baroness, Lady Warwick, was the first of several noble Lords to highlight the importance of the 2010 report, Fair Society, Healthy Lives. It highlighted that life expectancy is spread across a social gradient, a point highlighted by the noble Baroness, Lady Royall; namely, that the lower a person’s position, the worse his or her health. It recommended that action should be proportionate to the level of disadvantage.

Following on from that paper, our public health White Paper, Healthy Lives, Healthy People, accepted the review’s recommendations and we are sponsoring the UCL Institute of Health Equity, led by Sir Michael Marmot, to help implement them. We have adopted its approach. For example, on maternal and child health we are increasing by 50% the number of health visitors by 2015 and more than doubling the number of places on the family nurse partnership programme, which supports vulnerable, first-time young mothers.

Reducing health inequalities is a core Public Health England activity. It will be set out in its business plan to be published shortly, and its health and well-being framework in June. It will identify the action that many stakeholders—notably local government—can take. NHS England set out its proposed priorities in its December board paper Promoting Equality and Tackling Health Inequalities. In addition, NICE continues to provide evidence-based guidance, and the ONS will continue to publish much important data to support our efforts in reducing health inequalities. When I sum up, I will pick up on the issues around data mentioned by the noble Baroness, Lady Warwick of Undercliffe.

The noble Baroness will know of the importance of good health for women during and after pregnancy from her time at Bradford as a previous chair of Bradford Health Authority. Bradford is second only to Birmingham in the number of infant deaths. Responding to that challenge, Bradford established an infant mortality commission, drawing together partners from all corners of the city. Action in Bradford and elsewhere has had a national impact. The health gap in infant mortality was halved between 2004-06 and 2009-11, between the routine and manual group and the whole population, which shows that local focused action can reduce inequalities.

Different communities face different health needs, and it is for local areas to identify those needs. We have sought to empower local areas by transferring public health to local government, giving £5.46 billion of funding over two years. We have made it clear that local areas must take account of health inequalities as a condition of that funding.

Some of the most extreme health inequalities are found among the most vulnerable and socially excluded women, such as street-based sex workers. Open Doors, a Hackney organisation, and the TB team at Homerton Hospital carry out late-night outreach among these women looking for cases of TB and HIV—a fatal combination—and to provide support and care for them. The Homerton TB team also provides housing for homeless people with TB for the duration of their treatment because, as my noble friend Lady Suttie has said, homelessness helps spread TB. The £10 million Homeless Hospital Discharge Fund seeks to ensure safe discharge from hospital and to break the cycle of poor health and homelessness. Public Health England is leading on developing a national TB strategy, including tackling drug resistance.

The NHS is providing a hepatitis information and testing programme in Sheffield, which offers screening for at-risk communities, including the Roma communities, and in Leeds it is seeking to establish the needs of those communities and to improve access to their services. In Salford, the NHS is working with different groups to improve the uptake of vaccines such as MMR, focusing on BME groups where the uptake is low. In Hillingdon, a specialist health visitor and trained volunteers support Afghan and Tamil women on a range of physical and mental health needs, including domestic violence.

As noble Lords will know, access to services is crucial. Women living in deprived areas are less likely to attend for breast cancer screening or present with early symptoms, which leads to lower survival rates. We cannot meet our cancer objectives without reducing these inequalities through programmes such as the National Cancer Equality Initiative, and the work of local areas such as Southwark and Lewisham in reducing inequalities in breast cancer care, and Walsall and the Isle of Wight in promoting cervical cancer screening.

Obesity has a strong social gradient among women. We are encouraging and promoting action on obesity and better nutrition through the responsibility deal and through Change4Life. There is a threefold difference in smoking in pregnancy rates between London and the north-east. Sunderland and other north-east communities, Blackpool and Dudley have responded to these inequalities and are contributing to our national ambition of reducing smoking in pregnancy rates among all women from 15%—where it is now—to 11% by 2015.

We work—with Public Health England—across government to reinvigorate action on child poverty, raise educational attainment, support families and promote work as a route out of poverty. To pick up a point raised by the noble Baroness, Lady Warwick, a study by the Institute of Health Equity has shown that one of the best things that you can do for a child is to read to them daily. Not only does that raise their educational outcomes but it also raises their cognitive ability from a very early age.

I understand that. I am sure that there are adult education programmes across the country. The noble Baroness shakes her head. Perhaps we can have a conversation about that outside the debate.

We have focused on outcomes rather than on targets to promote action and measure progress, including through the public health outcomes framework, in line with the Marmot review proposal for a national framework of indicators for local areas to draw on to meet their own needs. This strategic approach to reducing health inequalities will help guide local action that is practical, joined up across the causes of ill health, and delivered at a scale to make a difference and improve health outcomes for all our people.

In what time I have, I shall run through points that noble Lords have raised that I have not covered. The noble Baroness, Lady Manzoor, asked about cardiovascular disease, which we know affects millions of people and is one of the largest causes of death and disability in this country. The previous Government made huge strides in this area which this Government have carried on. During the past decade, there has been a 40% reduction in under-75 mortality rates, with a narrowing in the difference between the most deprived and the least deprived areas of England.

Domestic violence is one aspect of violence against women and girls; others include sexual violence, abuse and gang violence. We also heard today at Question Time about FGM, and the Government are working on that issue.

On international health inequalities, raised by the noble Baroness, Lady Hayman, the approach to tackling health inequalities in England is recognised internationally as leading edge. Professor Sir Michael Marmot has chaired the World Health Organisation’s commission on the social determinants of health. Based on the interim analyses of the first phase of this programme, it is estimated that, during the lifetime of the project, more than 9,500 maternal lives will be saved, more than 190,000 maternal disabilities will be avoided, nearly 10,500 new-borns will be saved and more than 12,500 stillbirths will be averted.

The noble Baroness, Lady Warwick, asked about the gap of 20 years in healthy life expectancy. I mentioned earlier that local authorities have been given a £5.4 billion budget to press on that.

I have been informed that I am out of time. I am sorry. I flagged up that I doubted that I would get through all your Lordships’ points during the debate, but I will certainly write to you and answer any outstanding queries.