\U/C HOUSE OF COMMONS SESSION 1996-97 COMMITTEE OF PUBLIC ACCOUNTS Seventeenth Report HEALTH OF THE NATION: A PROGRESS REPORT Together with the Proceedings of the Committee relating to the Report and the Minutes of Evidence, and Appendices Ordered by The House of Commons to be printed 5 March 1997 LONDON: THE STATIONERY OFFICE £10.60 HOUSE OF COMMONS SESSION 1996-97 COMMITTEE OF PUBLIC ACCOUNTS Seventeenth Report HEALTH OF THE NATION: A PROGRESS REPORT Together with the Proceedings of the Committee relating to the Report and the Minutes of Evidence, and Appendices Ordered by The House of Commons to be printed 5 March 1997 ee = ; NF+ eSyE S R3 soat2 t 2 e MAR ti aRkSe a ea\ lM a cei )o b i EGeUceUo StH e +.A SNSy F SSA:O TPE2h5S5 eYe 7 II maaMaa in e0jo t ## / O. b ai \ ov ' C 9 7 i4 4 tf ‘ 53 LWaIrAtsM Cai oe Ce > -tae Sad]35 | ecdiiced ~ o™ ? , aoe Vy On i — LONDON: THE STATIONERY OFFICE £10.60 85 il SEVENTEENTH REPORT FROM The Committee of Public Accounts is appointed under Standing Order No. 122 viz: Committee of Public Accounts 122.—(1) There shall be a select committee to be called the Committee of Public Accounts for the examination of the accounts showing the appropriation of the sums granted by Parliament to meet the public expenditure, and of such other accounts laid before Parliament as the committee may think fit, to consist of not more than fifteen members, of whom four shall be a quorum. The committee shall have the power to send for persons, papers and records, to report from time to time, and to adjourn from place to place. (2) Unless the House otherwise orders, each member nominated to the committee shall continue to be a member of it for the remainder of the Parliament. (3) The committee shall have power to communicate to any committee appointed under Standing Order No. 130 (Select committees related to government departments) such evidence as it may have received from the National Audit Office (having been agreed between that Office and the government department or departments concerned) but which has not been reported to the House. The following is a list of Members of the Committee since its nomination on 22 May 1992. The present Members are those marked with asterisks. *Mr Robert Sheldon (elected Chairman 10 June 1992) Mr Michael Ancram (discharged 26 July 1993) Mr D N Campbell-Savours (discharged 9 June 1992) *Sir Kenneth Carlisle (added 16 February 1995) Mr James Couchman (discharged 21 November 1995) *Mr Denzil Davies Mr Terry Davis (discharged 23 May 1994) Mr Stephen Dorrell (discharged 18 October 1994) Ms Angela Eagle (added 28 November 1995) (discharged 11 November 1996) *Mr Mike Hall (added 9 June 1992) Mr John Horam (discharged 31 March 1995) Dr Kim Howells (discharged 10 December 1993) *Mr Michael Jack (added 17 October 1995) Mr Robert Jackson (added 26 July 1993) (discharged 17 February 1994) *Mr Robert Maclennan Mr Alan Milburn (discharged 28 November 1995) Sir David Mitchell (added 22 February 1994) (discharged 2 March 1995) Mr George Mudie (added 10 December 1993) (discharged 20 January 1995) Mr David Nicholson (discharged 22 February 1994) Mr Richard Page (discharged 16 February 1995) *Mr Andrew Rowe (added 21 November 1995) *Sir Michael Shersby *Mr Tim Smith (added 2 March 1995) *Mr Michael Stern *Mr Gerry Sutcliffe (added 11 November 1996) Mr Peter Thurnham (added 31 March 1995) (discharged 24 October 1996) *Mr Richard Tracey (added 17 February 1994) *Mr Charles Wardle (added 24 October 1996) *Mr Mike Watson (added 20 January 1995) *Mr Alan Williams Sir George Young (added 18 October 1994) (discharged 17 October 1995) The cost of preparing for publication the Minutes of Evidence published with this Report was £5,095.00. The cost of printing and publishing this Report is estimated by The Stationery Office at £885.36. THE COMMITTEE OF PUBLIC ACCOUNTS ili TABLE OF CONTENTS SEVENTEENTH REPORT Introduction and summary of conclusions and recommendations ... Progress towards the 27 Health of the Nation targets Limitations on the Department’s ability to monitor progress Health of the Nation as part of the NHS Planning Framework PROCEEDINGS OF THE COMMITTEE RELATING TO THE REPORT EVIDENCE (Wednesday 6 November 1996) MEMORANDA INCLUDED IN THE MINUTES OF EVIDENCE Memorandum by the Comptroller and Auditor General (PAC/7) WITNESSES Sir Graham Hart, KCB, Permanent Secretary and Dr D McInnes, Head of Health and Monitoring (Health Promotion Division), the Department of Health ne Mr R Le Marechal, Deputy Comptroller and Auditor General and Mr F Martin, Second Treasury Officer of Accounts : : : APPENDICES 1. Comparative charts showing the incidence of HIV Reports and AIDS cases in the United Kingdom from 1985 to 1990 (PAC/90) 30 2. 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Misclennaly ‘Wir Again We erss tinchiecnell 28N ovember 1905) = ia . Grr wid More heli (added 22 Fubniary StSChaayyt ard3 M e Wis Cicdres Muuse (added FO Tiecener 19 Vib. David (igholsof (dmehenste2 2 Tales Mr Richard Page (disc) 40 Pebraagels “hh Andrew Rowe Paicea t November i “Sit, Michael Shersoy vir Sem Simith tedaed 2 Mie Kenel "ir Mictulgd Saern., de firy Sisal fa Tee. ree SEVENTEENTH REPORT The Committee of Public Accounts has agreed to the following Report: HEALTH OF THE NATION: A PROGRESS REPORT INTRODUCTION AND SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS C&AG’s Report, 1. The Health of the Nation is a wide ranging strategy, led and co-ordinated by (HC 656 of the Department of Health and is the central plank of government policy on health Session in England. The aim of the strategy, which was launched in 1992, is to improve 1995-96), the health of people in England in five key areas. These are: Preface * Coronary heart disease and stroke; C&AG’s Report, Table 1 * Cancer; * Mental illness; * HIV/AIDS and sexual health; * Accidents C&AG’s Report, The Department set 27 targets within these areas to monitor progress. (HC 656); Evidence pages 2. On the basis of the report by the Comptroller and Auditor General, and 1-11; memoranda from him and the Department updating data in that report, we exam- National ined what progress had been made towards the 27 targets, the limitations on the - Statistics ability of the Department to monitor progress and the part played by the Health of Monitor MB1 96/2 (Table 1) the Nation strategy in the NHS planning framework. 3 Our main conclusions and recommendations are as follows: Progress towards the 27 Health Of The Nation targets (i) We are encouraged that good progress has been made towards 11 out of the 27 targets, particularly on coronary heart disease and stroke and some cancers. We note the extent to which the improvements reflect develop- ments in medical techniques and health screening programmes, and that the causes of these diseases are complex. We encourage the Department to build on their success in making further progress towards achieving these targets (paragraph 33). (ii) We are concerned that obesity in adults increased, when the targets are set to reduce obesity in men by 25 per cent and in women by 35 per cent by 2005. This is particularly worrying because obesity is known to be a risk factor in coronary heart disease, stroke and many other diseases. We note the Department’s evidence that there has actually been a reduction in the number of calories people consume, and that the rise in obesity reflects a long-term decline in the amount of physical exercise people take on average. We note too that, with hindsight, the Department consider their targets were too ambitious. We recognise that progress in this area de- pends on individuals deciding to alter their life styles, and that the Department are co-operating with others to promote increased levels of physical activities and reductions in the consumption of fat (paragraph 34). (iii) We are also concerned that the number of women drinking more than 14 units of alcohol a week had risen to 13 per cent by 1994, as against the target of 7 per cent by 2005, and by the effects this will have on the incidence of disease and alcohol-related accidents. We note that the Department do not have the evidence which links levels of household income with the consumption of alcohol. We consider that they will need to do more to assess the reasons for the increase in consumption before they can devise effective measures to counter it, through more closely directed health education programmes (paragraph 35). vi SEVENTEENTH REPORT FROM (iv) We are dismayed by the rise in teenage smoking, and that the Health of the Nation target of reducing smoking amongst 11-15 year olds to six per cent by 1994 has been missed. The actual level in 1994 had risen to 12 per cent. Teenage smoking will have consequent ill effects on the population including the incidence of cancer and vascular disease, and this rise may impinge on other Health of the Nation targets in the future. We look to the Department, together with the Department of the En- vironment and the Department for Education and Employment to explore what further action can be taken to reverse this trend (paragraph 36). (v) The Committee take note of the steep year-on-year rise to 1988 in cases of skin cancer and, although these trends appeared to have levelled off up to 1992, that the latest information showed a further rise. We also note the Department’s evidence that changes in behaviour in this area would not show up in the statistics for another ten or 15 years, because these were very long-acting effects. As most of the cases are avoidable, we urge the Department to consider what more can be done to reduce the incidence of this disease, through further improvements in health edu- cation (paragraph 37). (vi) We note that conceptions among girls under 16 fell by about 20 per cent following the peak in 1990, but that the 1994 figures showed a rise. We also note the continuing action being taken by the Department to make family planning available to under-aged girls, and that recent initiatives such as a freephone advice service called Sexwise had had a huge take-up. We look to the Department to continue to monitor the position and, if there is a further rise, to consider what further action could be taken to keep the trend moving downwards (paragraph 38). (vii) We are concerned that important illnesses, such as prostate cancer, are not part of the Health of the Nation initiative and might therefore not attract sufficient attention and resources. We therefore urge the Depart- ment to ensure that health issues excluded from the initiative are not neglected and that opportunities are taken to develop and extend the strategy where new areas of concern emerge (paragraph 39). (viii) We welcome the cooperation between Departments concerned with Health of the Nation, but we look to the Department of Health to ensure that they maintain and build upon this initiative, especially in those areas where progress against the targets is slow, or moving in the wrong direction (paragraph 40). Limitations on the Department’s ability to monitor progress (ix) We are concerned that a working definition of severe mental illness has not yet been agreed, and at the length of time it is taking to gather data on the incidence and severity of mental illness. While we welcome the work of the Clinical Outcomes Group in this area, we are very con- cerned about the impact this lack of data could have on effective services for the mentally ill, and we urge the Department to take immediate action to agree a working definition and to provide national data on mental illness (paragraph 53). (x We are disturbed at recent reports of a rising number of suicides among — Asian women. We note that the Department has started a special re- search project looking at deliberate self-harm, including suicide, among young Asian girls, to help guide the design of interventions to reduce deliberate self-harm in this group (paragraph 54). (xi) We are disappointed that, as yet, there is no indicator which specifically monitors the development and spread of HIV and AIDS. We note that the number of new cases of AIDS has levelled off, reflecting the estab- lished trend in new HIV cases, and that the UK compares well with other European countries. We note too the Department’s view that this con- THE COMMITTEE OF PUBLIC ACCOUNTS Vii SS tainment in the United Kingdom is likely to be associated with a number of factors including the early introduction of a public education cam- paign in the mid—1980s. We also note that, because the projected number of cases of AIDS had fallen 10 per cent below the number forecast in 1993, spending on treatment and care was expected to fall from £195.1 million to £185.7 million in 1996-97, as would central spending on health education, from £6.45 million to £3.64 million. We consider it important that the Department complete their work on devel- oping a suitable target in this area, to help them better target the funds available and their interventions at vulnerable groups (paragraph 55). (xii) We are disturbed that no national data is yet available on a consistent basis to monitor trends of drug users sharing injecting equipment, an important mode of transmission of HIV, and that the lack of data could impair the planning and delivery of AIDS and HIV services. We look to the Department to review the target when data from their 1997 survey is available so that comparability may be achieved (paragraph 56). Health of the Nation as part of the NHS planning framework (xiii) We support the development of specific health targets, to help focus attention on health areas which most need to be addressed, and to set clear goals useful to the NHS and others (paragraph 67). (xiv) We note that the Department is keeping under review the targets and action plans which underpin Health of the Nation, and we look to them to continue to be aware of the need to revise targets, or to set new ones, where new information emerges (paragraph 68). (xv) We note that, in some areas, such as coronary heart disease, although good progress has been made towards the targets, the United Kingdom still has far higher death rates than many European Union countries: on coronary heart disease and lung cancer the United Kingdom is second highest amongst the 12 founder member countries of the European Community. We note too that increased European Commission activity, particularly in developing a health monitoring action plan, could lead to better informed comparability of data. This in turn, could help the Department understand the complex reasons for the variances and in- form their target setting (paragraph 69). (xvi) We note the Department’s approach to piloting health promotion cam- paigns and evaluating the results, as well as to developing ways of better targeting action plans, such as developing links between targets and action plans and socio-economic data. This is an area at the heart of the Health of the Nation strategy and where substantial sums are spent: some £210 million on health education and promotion each year. We therefore look to the Department to ensure that their programmes are well targeted and effective (paragraph 70). PROGRESS TOWARDS THE 27 HEALTH OF THE NATION TARGETS 4. There has been encouraging progress towards 11 out of the 27 Health of the C&AG’s Report, para 8 and Nation targets. However, there are three areas: obesity; drinking by women; and Table 3 smoking by children aged 11—15 years, where the trend is moving in the opposite direction. There are other areas: for example, skin cancer and conceptions by girls under 16 years, where some progress has been made but there is cause for concern about the pace of change. AREAS WHERE PROGRESS IS ENCOURAGING (a) Coronary heart disease and stroke 5. The target is to reduce the number of deaths from coronary heart disease in C&AG’s Report, Table 2 and people aged under 65 by at least 40 per cent by the year 2000 (from the baseline pages 12-16 of 1990), and by at least 30 per cent in those aged 65-74 years. The aim is also to reduce the death rate from stroke in people in both age groups by 40 per cent Vili SEVENTEENTH REPORT FROM Evidence, over the same period. In practice, positive progress has been made against all these page 4, Figure 1 (Al, A2, A3 and targets. A4) Q2 6. We asked the Department to what they attributed the decline in numbers. They told us that in all these cases the position was extremely complex and that they did not necessarily know all the factors at work. However, some of the factors at work, both before and after the targets were set, were the reduction in smoking, improvements in the treatment of coronary heart disease, and the introduction of new drugs, for example to treat heart attack victims. They also mentioned the frequency with which people with coronary heart disease could be operated on for bypass grafting or similar procedures. The Department added that they needed to go on improving and making these kinds of changes in the future in order to keep the line on the graph moving downwards: it would not move downwards on its own accord; it was a reflection of changes in society, changes in medical treatment and so on, on which they had to try and maintain the momentum. (b) Cancer C&AG’s Report, 7. The latest figures for breast and cervical cancer showed progress towards the Table 2 and targets set in Health of the Nation. However, we put it to the Department that, in pages 26, 27, 28 view of screening procedures, one might have expected more significant improve- and 30-31 and ments. Evidence, page 7 (B1, B2, B3, B4, 8. The Department told us that there had been a 13 per cent reduction in the BS) Q6 death rate from breast cancer between 1990 and 1995 and that they were on target to achieve a 25 per cent reduction over a ten-year period. They were very pleased with the way the breast screening programme was going: there was a high level of coverage and a large number of cases were being diagnosed early. 9. On cervical cancer, the Department provided additional information for Office of National England which showed that the implied Health of the Nation target of 12.8 Statistics registrations per 100,000 population per annum by the year 2000 had been (Monitor: achieved in 1991. Population and Health (MBI 10. On deaths from lung cancer in women under 75 years of age, we asked the 96/2: Page 3)) Department whether they still expected to meet their-target of reducing the death (5.11.96) rate per 100,000 by 15 per cent by the year 2010, given that the rate had actually Q8 risen in 1994. The Committee were told that the general point about a lot of these conditions, and particularly the cancers, was that the results of doing certain things like smoking might take a very long time to come through in some noticeable effect on health. A reduction in lung cancer in women was being experienced but it was quite gentle. The Department hoped and expected that the reduction would continue to be fulfilled and might even accelerate a little. AREAS WHERE PROGRESS IS LIMITED (a) Obesity C&AG’s Report, 11. The target is to reduce the percentage of men aged 16 to 64 who are obese para 8 and Table by 25 per cent and women by 33 per cent by the year 2005. In fact, the trend is 3, and pages 20 rising. We therefore asked the Department why this was, given all the publicity and 21; and concerning cholesterol and saturated fats. Evidence, page 5, Figure 1 12. The Department told the Committee that the statistics were a reflection of (A7) Qs 3+4 two factors: obesity and overweight. One was the issue of how much physical activity we take, and the other was the issue of how much we eat and drink. What we were seeing in our country and in a lot of other western countries was a long-term decline in the amount of physical activity we take on average. Although there was also a decline in the calories we actually consumed, there was a growing imbalance between what we expend in calories and what we take in. 13. We asked the Department how they expected improvements to be achieved. Q5 They replied that they could draw this issue to people’s attention, which they did pretty rigorously. They had a serious campaign under way to try to persuade people to raise their levels of physical activity; they had given, and were giving, a lot of advice to people about diet and what they ate, and were working with a lot of the players in this field, with the food industry and others, to try to bring