Alan Milburn – 2002 Speech to the Faculty of Public Health Medicine

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 20 November 2002.

It’s a privilege to be here today as guests of the Royal College of Obstetricians and Gynaecologists. For fifty years the Royal College has worked tirelessly to make pregnancy and childbirth safer for women and babies. Your work has made an immense contribution to reducing deaths during childbirth. And that contribution has been particularly important because it has been most measured amongst the poorest communities in our country where need is greatest.
I am also grateful to the organisers of today’s event – the Faculty of Public Health Medicine. For thirty years it has set the standard for public health not least by driving major improvements in training and personal development. I want to thank you for your leadership and your support.

Today I want to describe the national challenges we face in improving public health and tackling health inequalities. I also want to set out our national programme of action to address them.

My starting point is this: the health debate in our country has for too long been focussed on the state of the nation’s health service and not enough on the state of the nation’s health.

In my view the time has now come to put renewed emphasis on prevention as well as treatment so that we develop in our country health services and not just sickness services. It is time for a sea change in attitudes. A renewed determination to fulfil the ambition we should share as a nation: to improve the health of all and to improve the health of the poorest, fastest.

The key questions today should be about how best we can bring about that improvement in the public’s health. How best can we cut deaths from heart disease? How best can we improve cancer survival rates? How best can we add years to life and add life to years? And crucially, how best can we tackle the huge inequalities in health which scar our nation?

In the last five years we have made a start in answering these questions. And I want to thank the people working in public health from all the different health professions – alongside countless other dedicated staff working in the NHS – for the real difference you are making.

Together, we face formidable problems. Our rates of Coronary Heart Disease for example are amongst the highest in the world. Our cancer survival rates are too low.

Progress, however, is underway. Indeed, Britain now has the fastest improving heart and cancer services anywhere in Europe.

The latest data, covering the period from 1998 to 2000, shows that deaths from cancer have fallen by 6%, from heart disease by 14%. Just two weeks ago Professor Peter Boyle told us that the UK has had both the largest fall in lung cancer amongst men and the largest decline in breast cancer in the European Union.

There is a similar story on teenage pregnancy. We still have the highest rates in Europe but after years when teenage pregnancy rates rose they are now beginning to fall.

The introduction of the Meningitis C vaccine has reduced deaths by 90%. So new standards and new services are making their impact felt. But there is a long way to go. And I believe the time is now right to up our nation’s game on public health.

I say that for three principal reasons.

First, because for the first time in the history of the health service there is a long term commitment to extra NHS resources and to a ten year NHS plan for reform.

Improving public health – and tackling health inequalities – is a battle for the long term. It can’t be done when there is the uncertainty of spending being up one year but down the next. Today, after decades of neglect and underinvestment, we can look forward to the future with confidence. Five years of real terms growth averaging 7.5% a year will take health spending in our country beyond the EU average. Just six years ago spending on the NHS was falling in real terms. By 2008 it will have doubled in real terms.

Britain now has the fastest growing health care system of any major country in Europe.

To get the best from this level of investment – especially for our poorer communities – resources have to be accompanied by change and reform. The emphasis the NHS Plan places on improving health and reducing inequality has enjoyed insufficient attention since it was published two years ago.

The NHS Plan committed the Government to achieving the first ever national health inequalities targets; to increasing resources in deprived areas; to introducing new screening and preventative programmes. And in each of these areas there is already progress underway.

Second, however, renewed emphasis is needed on public health because there are new problems to deal with which make the challenge of health improvement both more difficult and more vital.

In an open, increasingly global economy disease recognises no boundaries. The rising incidence of TB across the under-developed world is now impacting on the developed world – including in this country.

Changes in lifestyle are having an impact too. Sexually transmitted infections are rising especially amongst young people. Over the last few years more people newly diagnosed with HIV were infected through sex between men and women rather than sex between men.

Obesity has trebled since 1980 – increasing the risk of heart disease, diabetes, stroke and some cancers. It is more common amongst lower socio-economic groups with unskilled women twice as likely to be obese as professional women.

There are similar trends in tobacco consumption. By the age of 15 around one quarter of girls are regular smokers. Not surprisingly while rates of lung cancer are falling among men they are still rising among women. Indeed lung cancer has now virtually caught up with breast cancer as the leading cause of cancer deaths among women. The problem is greatest amongst lower income women.

In each of these cases we have responded with new services and new approaches. But as the Chief Medical Officer’s report, Getting ahead of the curve, made clear new challenges mean that we must keep focussed on public health. Indeed that is why we are creating a new Health Protection Agency. And there is another pressing reason for upping the focus on public health – health problems, old and new, are all too often concentrated in the poorest communities.

Third, then, for over fifty years the health gap between the better off and the worst off has widened, not narrowed. For me, that offends against all this government stands for: a society based on fairness and justice, in which each citizen gets the opportunity to fulfil the potential of all their talents. Good health – like a good education – is the route by which each and every one of us can properly fulfil our true potential. It unlocks life chances and is a fundamental building block of wellbeing.

Too many people are denied this basic chance in life. That was principally the message of Sir Donald Acheson’s report. Poorer people get sick more often and die earlier. For us it is simply unacceptable that the opportunity for a long and healthy life today is still linked to social circumstances, childhood poverty, where you live, how much your parents earned, how much you earn yourself, your race and your gender.

In some areas of the country life expectancy is still the same as the national average in the 1950s. Two weeks ago the Office of National Statistics published new figures showing that even today a boy born in Manchester would live on average a decade less than a boy born in Dorset.

Social inequality breeds health inequality. Poverty literally cascades down the generations. Up to a quarter of all children are persistently in low income families. Babies born to fathers in social class five are more likely to be low birth weight. Low birth weight is a key factor in a child’s subsequent development and opportunity. Poor children are less likely to get qualifications and to stay on at school. Poor health then is linked to low educational attainment, which is not only bad for the individual but also bad for the nation.

Economic success today depends on harnessing the skills and potential of all of our people and not just some. Poor health blights too many communities and holds back too many people.

So, the time has come to recognise that health just like education is a route to economic fulfilment as well as personal fulfilment. Just as good education is a route out of social exclusion and into economic prosperity so too is good health. The vicious cycle of poverty, social exclusion, educational failure and ill health must now be broken.

It is this determination which drives the Government’s programme to reduce child poverty. Our aim is to reduce the number of children in low income households by at least one quarter by 2004 as a contribution towards our broader target of halving child poverty by 2010 and eradicating it by 2020.

Today on International Children’s Day it is worth reminding ourselves that compared with just five years ago, Britain has a quarter of a million fewer children growing up in homes where no-one has a job. 1.4 million fewer children live in absolute poverty today compared with five years ago. Almost 300,000 children in disadvantaged communities are already covered by Surestart, offering them the start in life others are able to take for granted.

Youth and long term unemployment are at the lowest level for 25 years. There are 1.5 million more people in work. The minimum wage and the working families tax credit have raised the living standards of millions of poorer families. There is more investment in childcare and in poorer communities. But there is an awfully long way to go.

By intervening in these sort of ways to break the cycle of poverty we can effect what Anthony Giddens once called the “redistribution of possibilities”.

Our task as a government is to ensure that the “redistribution of possibilities” becomes a reality for every section of society, every community in every part of our country.

Our vision is of a society where there are opportunities for all and not just for some. Where everyone does enjoy the chance to get on. The opportunity of a job. The opportunity of good education. To live in a community free from crime and the fear of crime. The opportunity to enjoy better health too.

So there is every reason in the world to take action to address health inequalities and improve public health. The necessary levels of investment are in place. We have a long term plan for reform. Without action the problems are likely to intensify. Above all – perhaps most simply of all – health inequalities offend against the values of social justice, the very values on which the NHS was founded.

And yet, for years there has been a sometimes paralysing debate about whether we could do anything to tackle health inequalities at all. Some argued that since they were the product of such deep-rooted social and economic factors they were beyond any realisable form of action from the NHS or indeed any other agency. Others argued – even when they were in government – that it was the individual rather than society that was to blame. Both analyses became a recipe for hopelessness and inaction.

Today we need a new outlook. An approach that accepts that there are wider determinants of ill health – and a wide-ranging programme of action is necessary and indeed is underway to deal with them. But an approach which also understands that the NHS can make a specific contribution to improving health prospects by working with the communities it serves: making the task of tackling health inequality something done with local people not just done to them. Indeed, such action is vital if the NHS is ever to deliver on its values of equity and social justice.

Today our insight surely must be 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 – and not just between government departments but between government, business, local communities and individuals to provide real and lasting opportunities for better health. And it calls for a renewed effort on the part of the NHS to focus on prevention so the “redistribution of possibilities” becomes a reality.

Today I am publishing the Government’s cross cutting review on health inequalities, part of this year’s Spending Review. The review commits – not just one government department but the whole of Government – to place tackling health inequalities at the very heart of public service delivery. So with the education department we will extend Surestart. With the transport department we will improve public transport in deprived communities. With local government we will improve the housing stock.

The Prime Minister will take a personal lead in addressing the inequality issues raised in the review. He will be chairing a meeting of cabinet colleagues to oversee the production of a detailed national programme of action on health inequality.

Within the Department of Health I am establishing a new Health Inequalities Unit. It will help lead our health-specific efforts on tackling these inequalities.

With resources biting alongside reforms, and with the focus on the long term not merely on the short term, we can now increase our emphasis on health prevention as well as treatment. This can not be 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 diets are often less healthy and smoking rates are higher in poorer communities. That acknowledges people have the right to make a choice about what they eat or whether they smoke but people should have the opportunity to have a healthier diet or to give up smoking if they so choose. Many are denied that opportunity because healthy food has not been available locally or until recently because help to give up smoking has not been available freely. It is on this basis that we can then ask people to take greater responsibility for their own health.

There are five specific steps we now plan to take.

Firstly, tackling inequalities in access to health services.

The most disadvantaged are not only more likely to get ill. They are less likely to get the best services when they are ill. You can see that in the way those parts of the country that have the worst levels of heart disease often have the worst heart services.

We have started to address this inverse care law – whereby those with the greatest need tend to get the least health care – that has dogged the NHS for fifty years. Equity demands national standards that level services up not down. The national framework of standards we have put in place – with national service frameworks and a national system of inspection – are a means to this end. So too, despite the controversy around them, are national targets to ensure equity in access to treatment.

The targeting of resources to areas where need is greatest is also important. In tertiary care for instance we are plugging historic gaps in heart surgery capacity by putting in place new services in Teesside, Blackpool, Wolverhampton, Bristol, Plymouth and elsewhere. In primary care GPs working under the personal medical services contract are delivering services in communities where none existed before like Sunderland, Salford, East London and Liverpool.

Two years ago I introduced the health inequalities adjustment into the NHS funding formula to ensure that extra resources were going to the areas of highest health need. Later this year I will introduce an entirely new formula for funding local health services so that we can achieve a better balance still between high cost areas and high need areas.

Secondly, then, we plan to put public health and addressing health inequality at the heart of the NHS. By devolving power in the health service we have begun to put public health centre stage. The truth is the fifty year old one-size-fits-all NHS hasn’t succeeded in reducing health inequalities. Uniformity in provision has not guaranteed equality of outcome. That is why we are moving towards an NHS where standards are national but control is local. Since different communities have such very different needs it must be right to put resources and responsibilities in the hands of frontline services.

Today Directors of Public Health are based within local Primary Care Trusts, directly serving more than 300 local communities. There is a huge opportunity here for public health to take a hands-on community-orientated role; to use the PCT structures to forge local alliances – between public, private, voluntary and community organisations – which are necessary to tackle specific local health problems. And there is now a clear mandate to do so.

The two national inequalities targets we have set are now firmly embedded in the NHS Priorities and Planning Framework for the next three years. They are now core business for the whole National Health Service.

I can also say today that the next set of performance indicators on which all local health services will be rated and rewarded will have at their core securing improvements in public health and better health outcomes. We are considering indicators on infant mortality and mortality from circulatory diseases and cancer, alongside success rates for smoking cessation services, screening and immunisation.

Thirdly, we need to focus relentlessly on defeating our country’s biggest killers – cancer and coronary heart disease. Between them they kill over 200,000 people a year. Many of these deaths are preventable. Unskilled men are three times more likely to die from heart disease than professional men. Survival rates from cancer are worse in lower income areas than in higher income ones. Since both diseases have such a strong social class gradient a concerted effort here will make the biggest contribution to narrowing the health gap.

In the last three years since the publication of the national service framework on heart disease in 1999 and the Cancer Plan the year after, much progress has been made.

The number of cardiologists has risen by over 40% since 1997. The number of heart surgeons is up by more than 30%. There are 500 more cancer consultants today than there were in 1999. There are 500 more to come.

182 Rapid Access Chest Pain clinics are now open. The number of new linear accelerators has increased by 20%, CT scanners by 50% and MRI scanners by 100%. Again there are many more to come.

The best drugs are becoming available across the NHS too. Prescribing of statins to control cholesterol, while putting pressures on PCT budgets, is up by one-third. A few years ago taxanes to treat cancer were available – not according to clinical need – but according to the local chance of whether a GP or a health authority had decided to make them available to patients. Today they are available to all who need them, not just some. Thanks to the work of the National Institute for Clinical Excellence, over 30,000 patients can already benefit from new cancer drugs. Many more will do so in the years to come.

And, step by step, the NHS is making progress in tackling waiting times for treatment. Today 95% of patients urgently referred with suspected cancer are seen within a fortnight when they used to have to wait for months. The maximum wait for heart surgery is down from 18 months to 12 months. By spring next year it will fall to 9 months and will be lower still in future years particularly as more patients are able to make more choices about where they are treated.

In the next three years the NHS will be able to make further progress still by focussing not just on further advances in treatment – through faster waiting times and new drugs – but also on prevention.

Fourthly, we need to secure a better balance between prevention and treatment. Sir Richard Peto said earlier this year that halving the rate of premature death worldwide is within the capability of current medical expertise. We simply can no longer regard prevention as playing second fiddle to treatment. That is why we are extending our NHS screening programmes. Breast screening has been extended to 65-70 year old women. So far 130,000 women have been invited. By 2004, 400,000 women will be benefiting each year. Nationally, we will now move to extend other screening programmes such as for prostate cancer when there is the means to do so and for colorectal cancer as soon as we are able to do so.

Locally, more and more GP surgeries are already establishing registers of patients at risk of disease so that they can intervene sooner rather than later. Also, in this session of Parliament we are proposing to legislate for far-reaching reform of NHS dental services. PCTs, with the support of dental public health colleagues, will need to assess local oral health needs, including health inequalities, to meet their new responsibilities for dental services. Moreover, for the first time since the foundation of the NHS, primary care dentists will be given what is essentially a public health role, with the opportunity to focus on prevention and promotion, as well as treatment.

I hope that local PCTs will use their three year budgets to commission services in such a way that we get a better balance between services in the community and those in hospitals, between prevention and treatment. So that we can open up new opportunities for people to choose a healthier lifestyle.

We know for example that healthy eating could reduce by one-fifth deaths from cancer, stroke and heart disease. Fruit and vegetable consumption in our country is among the lowest in Europe – and still less in lower income groups than high income ones. Research I am publishing today on local five-a-day initiatives shows that those trends can be reversed. Those eating least before the schemes began ended up increasing their intake of fruit and vegetables once they had the opportunity to do so. Teachers have reported similar enormous benefits since we have introduced free fruit in schools. Today around 400,000 children are benefiting. By the start of the next school year it will reach 1 million children.

And the changes we are proposing to the welfare food scheme will open up choices for low income families to buy healthy food – including milk – for their young children. Together with the work the NHS is doing to encourage greater exercise – alongside partners like the New Opportunities Fund and Sport England – these opportunities to improve diet will not only help tackle the rising incidence of obesity but in the process help improve health and tackle health inequalities.

Fifthly, however the biggest contribution of all will be made by tackling smoking. As our 1998 White Paper starkly put it: smoking kills. It kills about 120,000 people each year in Britain. One in five of all deaths. It is the main avoidable cause of death. It is the principal cause of the inequalities in death rates between rich and poor. It costs the NHS £1.7 billion a year. Smoking is a public health disaster.

And yet we know that 7 in 10 smokers say they want to quit. Our job is to help them do so. That is why we have set challenging objectives to get smoking rates down not just among adults but amongst children. To target special help on lower income groups so that we can make most impact where the incidence of smoking is greatest. To help pregnant women to quit because smoking is the key preventable cause of low birth weight babies, one of the main determinants of future health.

We have made a start in delivering reductions in smoking. Smoking rates have fallen and the fall has been greatest amongst those in manual occupations. Now I want to set out how we will accelerate the drive to combat smoking.

To begin, with after years of obstruction in the courts and in Europe, the Tobacco Advertising and Promotion Bill received Royal Assent on 7 November. We made the commencement order giving start dates for implementation of the ban in Parliament yesterday. It comes into force today. By next Spring advertising on billboards and in the press will disappear. By next Summer tobacco companies will no longer be able to target their product at children because at long last tobacco advertising will be illegal.

What is more by this time next year, all cigarette packs will carry stark health warnings on the front of each packet. There will be new health messages including warnings about smoking causing impotence and clogged arteries. Misleading double-speak on cigarette packets such as “mild” and “light” will disappear.

Next year will also see, for the first time, tobacco companies having to provide information on the additives they put in cigarettes. We know already they include chemical compounds more usually associated with sweeteners and chocolate, solvents and turpentine. Each year we will publish the list of additives by brand and their known health effects.

With our European partners we will work to develop new graphic warning pictures on packets of cigarettes and other tobacco products. And we are working with the World Health Organisation to introduce a comprehensive Framework Convention on Tobacco Control to restrict tobacco advertising globally and improve tobacco control worldwide.

Our approach is not just about getting people to quit smoking but to make sure that people – especially young people- never start. The £59 million we have invested over the last four years in anti-smoking advertising is making a difference. These adverts have a higher recall rate than those of McDonalds. Elsewhere in the world where smoking prevalence has been dramatically reduced – places like Massachusetts, California and Australia – a major factor has been hard hitting media campaigns which have set out the reality of the damage caused by cigarettes. The impact, especially of TV advertising, has been just as high among low income smokers as amongst more affluent smokers. Research on the national tobacco campaign in Australia estimated a reduction in adult smoking prevalence of 1.8% over the initial 18 month period of the campaign. The costs of implementing it were more than offset by projected savings to the health care system.

Over the last few months my department has been discussing with some of our key health charities how we could learn those lessons from abroad and apply them here at home. I am pleased to be able to announce today that we will be providing an extra £15 million over the next three years to allow those charities – beginning with the British Heart Foundation and Cancer Research UK – to run similar hard-hitting campaigns here.

Let me just say at this point that I am grateful not just for the work of these two charities but for the work of countless others in tackling the scourge of smoking including the British Lung Foundation, the Royal College of Physicians, the BMA, ASH and QUIT.

And finally we will give more support to help more of the 7 in 10 smokers who say they want to give up smoking to do just that. Today the NHS is providing a genuinely world leading smoking cessation service. Zyban and Nicotine Replacement Therapy are already available on prescription. We began these services in the poorest communities and they are now available nationwide. Nearly 220,000 smokers have been helped to kick the habit, many for good. And now over the next three years we plan to help a further 800,000 smokers to quit.

We will do so by building up local services and developing our partnership with the pharmaceutical industry. Over the last few months we have been in discussion with GlaxoSmithKline, Glaxo Consumer Healthcare Novartis and Pharmacia about working more closely together to deliver even more smoking cessation services in local communities.

I am pleased to be able to tell this conference today that from the start of the next financial year we intend to have in place a rebate or a “cash-back” system between the Department of Health and these companies whereby the NHS receives a payment back for every extra smoking cessation product it buys over and above an agreed level.

We will in turn pass this cash back to local PCTs directly linked to how much they have invested in smoking cessation. The more they spend up front the more they will earn back. For the first time there will be a positive financial incentive to invest in public health. And we will want to explore how this principle could be extended further still.

We are engaged in a major national effort to tackle health inequality and improve public health. We need to mobilise individuals and communities. Above all else we need to mobilise you as public health professionals – without whom none of this would be possible – to lead it.

I have no doubt some people will dismiss this renewed commitment to public health and our campaign against health inequality as a road merely paved with good intentions.

But our actions are as determined as our ambitions are bold: to do what no government has ever done – to improve the health of the country as a whole and to improve the health of the worst off at a faster rate still.

Our determination springs not just from a recognition that health inequalities are in themselves an injustice but from a realisation that they hold our whole country back.

Our drive to tackle inequality comes not just from our view that a damage done to one is a damage done to all but our belief that to ignore health inequality is to tolerate even to condone it.

We do not condone health inequality. We must not tolerate it. It is time to tackle it. I hope that together we can do just that.