I, in common with other Members who have spoken, would like to add my appreciation for the fact that this motion is being debated today. I welcome the commitment of the Government and the Department of Health, Social Services and Public Safety to work energetically to tackle the root causes of preventable disease and disability and to reduce the inequalities in health status of our different population groups.

Perhaps I speak with a touch of cynicism, although I mean no disrespect to the Minister or anyone engaged in the struggle. When I first looked at this document I thought that it was good, decent, sound and that it reflected the way we wanted to go. However, after a second look, I said to myself "How much will we achieve? Does this mean anything, and, more importantly, will it ever mean anything to the vast majority of our people." I am talking about the ordinary people at street level who could be referred to in some circumstances as working class - people at the poorer end of the social spectrum.

Although I am concerned about the poor levels of health, health promotion and disease prevention across Northern Ireland, particularly among the working-class people, I am concerned about the plight of people in that socio-economic group in inner-city Belfast. My concern stems from knowledge gained while working for 20 years as a full-time GP in the inner city, and I continue to work there part time as circumstances here permit. Making my observations from that position, I view the health and disease promotion programme as all too often being middle class in its attitudes and values. Often it imposes these values on a working-class problem, which is not a solution for success. Often the language and expectations are different, as is the access to wealth.

Those who have resources can access better quality food, living conditions, housing and everything else. At a simple level it is easy to give someone a lecture on the dangers of the lard content of the Ulster fry and the risk it carries for coronary heart disease.

However, in many cases, people do not have - or do not perceive that they have - the option to adopt a healthier diet.

As a doctor in inner-city Belfast, I noticed that many of the resources, facilities and programmes operated out of relatively middle-class bases, such as Finaghy, Dunluce Health Centre and Holywood Arches. Although Holywood Arches Health Centre was adjacent to Sydenham and the working-class area of east Belfast, much of its catchment area was the area around Stormont. Such facilities were excellent for people with cars, but, in many cases, they were inaccessible, because the bus routes were unsuitable and, quite often, the people who needed to get to those facilities could not walk to them.

I worked in the Health Service on the lower Ormeau Road. We worked in the original health centre in three old terraced houses. There were few resources and only limited facilities to serve a deprived inner-city community that crossed the divide. We covered the Markets area, Sandy Row, Donegall Pass, lower Ormeau, Annadale and the lower Ravenhill Road. Those were the people who could not access the facilities that they needed. Not only were those areas deprived, but they were hammered by the troubles and the social unrest of the last 30 years.

In that period I and others like me struggled to obtain recognition and investment for that deprived inner-city community from the former Department of Health and Social Services. For all those years, we were on a continuous merry-go-round. I first started discussions about a new building 16 or 17 years ago. The present building has been condemned for health and safety reasons, but we must survive in it. There are no modern facilities. Indeed, the support services that we had have been taken away. I am not talking about my own practice; I am talking about a facility that, at one stage, served most of south and east Belfast. It has shrunk as other people have picked up some of those services, but, by and large, it still delivers a service of sorts to the deprived inner city. There has been pain, grief, worry and stress in that area. The problem is far too important to be entrusted to the Department. The problem is not one of bureaucracy or architecture; it is about providing services for people, and that is where our Health Service falls down.

People could, perhaps, accuse me of pursuing self-interest; that is not so. I intend to withdraw entirely from general practice in the next year or two. However, I want to see adequate resources and healthcare provided for people in the inner city. Judging by what I have seen, there is too much morbidity and ill health in that area. Too many people die young from a whole range of illnesses. Many cases could have been treated or cured, had they not been neglected. Although much of the neglect is the responsibility of the patients themselves, the lack of access to facilities and the absence of a welcoming centre in that area mean that the treatment of cancers, heart disease and other illnesses is put on the long finger.

I do not want to be emotional or sentimental about it. There are gaps, and we do pay a lot of lip service. I am not accusing our current Minister, because this has gone on for many years. However, until something is done about similar situations we will not have done anything for the Health Service, and we will not have the Health Service of which we want to be proud.

We can say that we have lots of wonderful programmes and policies. Those dealt with issues such as women's health - an issue that particularly concerns me. While the programmes and policies are available, they can only penetrate those who can access them intellectually and physically. Many programmes miss working class people in the inner city totally. They pass those people who have been battered for the past 30 years by social unrest.

At times over the past 12 years I have been conscious about the problems in women's health and of the fact that a mere male can do only so much. During that time I enlisted three female partners in order to set a high priority on women's health. We tried every possible way of communicating with the female population, but we could only get a 55% uptake in our cervical cytology efforts. Short of physically grabbing people in the street we could not get beyond that figure. People felt that they could not avail of that service. The Department of Health expected us to have a 75% or 80% uptake. We tried to communicate in ways that we thought people could relate to, but they declined the tests. There is an issue about how we communicate with people and encourage them to avail of proper healthcare after we have provided the appropriate facilities.

Some years ago we thought that we were doing very well. I had one male partner and three female partners, and we were all gung-ho on women's health. We decided to congratulate ourselves by auditing on our perceived success, and we interviewed 200 women between the ages of 45 and 55. We were quite sure that we would get a tremendous result of about 80% satisfaction because the women were in the surgery every week and, therefore, they had to be healthy.

However, the reality was that they were there every week as messengers for mothers, fathers, grandmothers, grandfathers, children, husbands or grandchildren. They were there as the contact point - the communicator. In many ways they were the secondary providers of healthcare for their families. From the 200 women we interviewed we found that approximately four were in reasonable health. The rest had problems.

I do not want to go into the gory details, but in this day and age, some of the problems were unforgivable. Many of the women had a significant degree of incontinence as a result of injuries received while giving birth 20 years before, or as a result of a clumsy or bad delivery. Many suffered from mental illness such as prolonged post-natal depression, which had not been diagnosed at the time.

One of the great revolutions in the Health Service was the provision of community psychiatric nurses 12 to 15 years ago. However, the service has been cut back to the point where it is barely viable. Community psychiatric nurses were a godsend 15 years ago, yet the service is now tight.

I have given you two examples of conditions that are unforgivable. I could say a number of other things. We pay a lot of lip service. We have a lot of nice reception areas and fancy brochures on breast cancer, cervical cancer, ovarian cancer and a whole array of things specific to women. We have to start putting this into real action and into a form that communicates to working-class people in deprived inner-city areas.

I have said enough, but I would like to switch to the other end of the spectrum before I finish. We spend a lot of time talking about cancers. Thank God, we are steadily winning the war against cancer, and the percentage curability of cancer tends to go up and up - not fast enough, but it is increasing. I am proud of my involvement - however limited - with the new cancer set-up in Belfast City Hospital. I believe that we will, in due course, have a world-class centre there.

I am distressed, however, that, in many such cases, we can be penny wise and pound foolish. Members are probably familiar with the gastroscope, the telescopic instrument that is passed down into the patient. That has been modified, and a version has been produced with ultrasound. It can produce a heart echo or a picture of a baby before it is born and can give an exact picture of a tumour. It is one of the most modern and essential pieces of equipment for diagnosing and assessing the treatability of cancer of the oesophagus, the stomach or the gullet. The surgeon knows exactly what he often has to treat.

That equipment costs about £120,000 or £130,000: we do not have one. I raised the matter with people in Belfast City Hospital and was told that efforts to gather together free funds have produced £90,000 to £100,000. In some cases, people are vulnerable to surgery. They have tumours in the oesophagus or the stomach, but they are perhaps not up to surgery. The surgeon needs to know what he or she is faced with before starting surgery and whether surgery will be too life-threatening to undertake at all. The only access to that equipment on the island of Ireland is in Dublin, and I understand that, in some cases, patients have been sent by taxi to Dublin.

We must get our act together. I emphasise that my concerns are in no way attributable to the current Minister, who has been in the job for less than two years. I support the motion; I say, "Hurrah! Let us get to grips with this!" We should get into more detail, and we need more papers on health. We should take a serious, practical look at the big gaps in provision and at the lack of funding. We must consider how we can provide a health service that meets the needs of people, without promising the world and only delivering half - or less.

Go raibh maith agat, a LeasCheann Comhairle. Tugaim mo bhuíochas do gach Teachta a labhair sa díospóireacht. Tá an-áthas orm gur spreag an t-ábhar oiread díograise, agus chuir mé suim sa mhéid a dúradh.

Dhearbhaigh an díospóireacht tacaíocht an Tionóil do chur chuige láidir trasroinne le sláinte ár bpobail a fheabhsú; cur chuige a chuireann cúiseanna sláinte agus easláinte go hiomlán san áireamh agus a athníonn go gcaithfidh dul i gceann éagothromaíochtaí sláinte go diongbháilte.

I am grateful to all the Members who contributed to the debate, and I am delighted that the subject has engendered so much enthusiasm. I listened with interest to all that was said. The debate confirmed - as, I hope, will the vote - the Assembly's support for a strong cross-departmental approach to improving the health of our people that takes full account of the causes of ill health and recognises the need to act resolutely to tackle health inequalities.

Several issues that were raised during the debate served to reinforce the argument that health improvement cannot be left to health services alone, or to Departments alone. That is why it is so important that all Departments and all sectors and agencies work together. The ministerial group on public health, which is made up of officials from all Departments and I chair, has designed a consultation process that is well beyond the usual and will engage all sections of society.

Several Members pointed to the need to improve specific services or ensure that sufficient resources are available to strengthen them. I assure Members that I support the case for adequate funding for all aspects of health and social services including mental health care for young people, the Ambulance Service, community care, primary care, acute hospitals and all other aspects that were mentioned.

It is especially important to ensure that health services are of a high quality and fully accessible to those who need them most, including people who live in isolated rural areas. My Department's equality scheme sets out how it will pursue access for designated equality groups. I outlined in previous debates steps that have been, and are being, taken by my Department on rurality, and Executive Colleagues outlined other steps during the debate on the Programme for Government.

'Investing for Health' is not just about treating disease or caring for the sick, vital as those things are. It is not a matter of traditional health protection activities, such as immunisation or improving food hygiene. It is not confined to the traditional health promotion messages to which Dr McDonnell referred to. It goes beyond the traditional approach to health education with its focus on persuading people to change their behaviour. It is not confined to the professional disciplines of public health medicine, health promotion or environmental health. The World Health Organisation defines health as

Public health has been defined as

It is important, therefore, that the emphasis in the consultation document is on the wider social determinants of health.

I am pleased to tell Members that the World Health Organisation contributed to the consultation on 'Investing for Health'. Its comments are extremely supportive and endorse our proposals as an excellent example of the World Health Organisation's preferred approach.

Mrs Carson and other Members asked what we will achieve in practical terms. Effective monitoring and accountability arrangements will, of course, be essential to the success of the strategy and to ensuring that it goes beyond a consultation document, a discussion and a strategy. The ministerial group on public health consists of senior officials from all the Departments, and it has been fully involved in developing the strategy. Group members will, in their respective fields, continue to play a key role in supporting its implementation. The ministerial group on public health that I lead will also consider, in the light of the consultation responses, what additional monitoring arrangements are needed for the new interdepartmental approach to ensure that the strategy happens and produces results.

Unsurprisingly smoking was referred to. It is one of the priority topics identified in 'Investing for Health'. I share the Member's concern about the number of young women who are taking up smoking. Our death rate from lung cancer among young women is already twice the western European average. The Health Promotion Agency has co-operated with the Midland Health Board region in the South to target smoking among young people through a television advertisement. We also looked at the importance of tackling smoking among young girls at school on an all- Ireland basis. The Department of Health and Children in Dublin has nominated a representative to our working group on tobacco that is developing an action plan to tackle smoking.

I thank Dr Adamson for his contribution about the positive role that the Belfast healthy cities project is playing. That project is much in keeping with the proposed approach outlined in 'Investing for Health' by focusing on the wider social determinants and working to broaden participation in action for health. I am pleased to hear about the progress that is being made, and I anticipate that the healthy cities experience will be built on as the investing for health process moves forward.

Mr Billy Hutchinson highlighted the need to maximise efficiency in the Health Service. Management and administrative costs in the health and personal social services (HPSS) are already closely monitored and controlled in order to maximise the resources that are available for care. Those costs amount to less than 2% of health and social service boards' total expenditure, and an average of 4.5% of the expenditure of trusts. Of course, it is paramount that we stress not only the need to get more resources for health, social services and public safety but to make the best use of those resources once we have them.

I agree with Mr Gallagher's comments on the significance of the rise of TB. I assure him that the number of cases of TB is not increasing here. In the year 2000 the number of cases here was at its lowest ever. The schools BCG vaccine and TB testing programme has recommenced this term, starting with children who are due to leave school this year. Other children who have missed the BCG vaccine will have the chance to get it from September.

On Mr McCarthy's point about radon, I am informed that the Environment and Heritage Service has offered 90,000 free radon measurements to households, but so far only 20% of households have taken up that offer. If a measurement is above the action level set by the National Radiological Protection Board (NRPB), remedial action is recommended, and grant assistance might be available. The Department of Enterprise, Trade and Investment is responsible for ensuring compliance with health and safety legislation in public buildings, workplaces and schools.

In regard to the safety of the measles, mumps and rubella (MMR) vaccine, my Department issued new information materials for parents and professionals in April. I agree with Mr Gallagher, who raised the point, and with other Members, that we must all stress the benefits and the necessity of immunisation.

A common theme that runs through all the issues raised by Members is that there not only needs to be action within the realm of health and social services, but also on issues that do not respect organisational boundaries and that demand integrated strategic solutions.

I am happy to report that good progress has already been made on the cross-departmental approach to addressing health issues. People have asked whether that would be a new beginning. Mr Morrow highlighted some of the actions that his Department is taking, and I am grateful to him and his officials for their contribution to the process. The Minister of Enterprise, Trade and Investment and I recently signed a joint statement of intent to address the issue of workplace health. The cost to the local economy of illness is immense, and we are committed to a programme of action to make workplaces healthier. I know that work will be done to establish an occupational health forum to meet these needs.

My Department has also been working closely with the Department of Agriculture and Rural Development to address the serious issue of stress in rural communities. Officials in my Department have been working with the Department for Regional Development to pilot a health impact assessment of that Department's regional transportation strategy. Those are examples of how, by working together, we can make a significant contribution to improving people's health. Through 'Investing for Health' we will be identifying further opportunities for such an approach. That will involve close consideration by all agencies of the positive steps that they can take to promote health, as well as the monitoring of any negative factors that impede good health. Monitoring will be part of the strategy development.

'Investing for Health' aims to improve health by broadening participation and action through partnerships which include community groups, voluntary organisations, businesses and statutory partners. It is important that people tell us what they need during the consultation period and during the implementation of the strategy.

The Members who have highlighted that also have a vital role to play. I hope that Members will feel stimulated by today's discussion to encourage the many people that they come across to respond to the consultation in a variety of forms. We have opened this up beyond the normal consultation processes - written responses and public meetings - by encouraging contributions through videotape or audio tape and other discussion forums. We have had a photographic exhibition sponsored by the 'Belfast Telegraph', and we have had sponsorship of drama from the Arts Council of Northern Ireland and others. There are a variety of ways in which people can make their views known.

I hope that the Members who have shown such interest today will also encourage people to make their views known, both before the end of the consultation process on 31 May and as the implementation of the strategy develops in the future. I also encourage them to ask people to think about what more they can do in their own lives to help improve the well-being of their families, friends and communities.

At the outset of today's debate I said that I wanted the consultation process for 'Investing for Health' to be truly inclusive. Everyone has the right to have their voice heard on issues that affect them, and no issue has more universal relevance than health. Therefore I encourage everyone to contribute. I will be taking into account all the views put to me, and they will be used to draw up proposals for the implementation of the strategy, which I intend to put to the Executive in the autumn. Those will be published, together with a report on the outcome of the consultation process, and there will be an equality impact assessment.

The next step is to ensure, as Members have said, that we have sufficient arrangements and resources in place to ensure effective implementation of the strategy and effective monitoring arrangements to see how it is brought forward. My intention is that it will come into effect from April 2002.

I thank all the Members who took part in today's debate. I hope that I have managed to address the issues they raised. Officials will scrutinise the record of the debate and, if there are points that I have missed, I will write to the Members concerned.

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