There's no question that poverty is bad for you. In 1999, the death rate from heart disease in the most deprived 20 per cent of health authorities in England was 26 per cent higher than the national average. The problems are myriad: poor diet, smoking and insufficient education combined with a lack of primary care facilities conspire to create a spiral of poor health.
Richard Sharp, health manager for the West Ham New Deal for Communities (NDC) project in Plaistow, East London, says: "In this area for example, we're seeing a disproportionate number of underweight babies, and higher levels of heart attacks, strokes and cancer than the national average."
By 2010, the Government is committed to closing the gap on infant mortality and life expectancy. In Newham, for example, those under 65 are 70 per cent more likely to die of a heart attack, stroke or related diseases than in England as a whole.
In addition, the Government aims to reduce the teenage pregnancy rate in the worst fifth of wards by up to 60 per cent. This will be achieved through implementation of a 10-year strategy to halve the national teenage pregnancy rate by 2010 and increase the participation of teenage parents in education, training or employment.
Teenage pregnancy is a key health inequality issue – girls from the poorest backgrounds are 10 times more likely to become teenage mothers than those from the richest, and the infant mortality rate for babies born to teenage mothers is more than 50 per cent higher than the average, accounting for 12 per cent of all infant deaths in 2000.
Behind this depressing scenario lies a shortage of GPs, which forces people to rely on accident and emergency units. Understaffed practices with outdated buildings and facilities make it difficult to persuade new healthcare workers to take the risk of settling in the poorest neighbourhoods.
Change is afoot. The Government is placing primary care at the forefront of its reform programme for the NHS. Primary Care Trusts are being established throughout England with a remit of placing local clinicians in the driving seat of change. In 2001, the Government promised to invest £1bn in primary care premises over the next three years.
Meanwhile, GPs are being wooed with golden hellos: £5,000 for every newly qualified GP is further topped up by another £5,000 for those who are prepared to work in the most deprived practices. Slowly, the situation is improving. In Sunderland, for example, a recent initiative recruited two more GPs to a deprived area and saw accident and emergency service attendance drop by 42 per cent.
But it's not just a question of increasing staff and sprucing up surgeries. Different communities have different health needs. Consequently, the NHS Plan sets out a whole raft of measures aimed at giving local health services flexibility over how they manage the patients in their community. This has been supported by a move to shift the balance of power from government to the front line.
At the heart of these changes are the Primary Care Trusts (PCTs), which are becoming the cornerstone of the local NHS. Led by clinicians and local people, they will be responsible for assessing need, planning and securing all health services and improving health. They will be rooted in local communities typically covering populations of around 150,000. There are some PCTs already in existence and the majority will be on stream throughout England by April this year.
PCTs will engage local communities and the Local Strategic Partnership in decisions that affect provision of health services. To ensure PCTs can deliver this new world, the Government is also making provisions to allow PCTs to have control of 75 per cent of all the NHS annual budget. This will mean that PCTs will have the resources to back up their new responsibilities for improving health and securing services for the local population.
PCTs will be responsible for the public health role previously undertaken at a health authority level and will need to concentrate on real interventions to improve health. They are already being encouraged to address gaps in local health services in a number of ways. Take, for example, Local Development Schemes. These provide extra funding for GPs who wish to set up special services to particularly needy local groups, such as drug addicts and the homeless.
Another means of improving local service provision is offered by the Personal Medical Service (PMS) scheme. This allows much greater flexibility over contracts with primary care staff, enabling the PCT to address specific gaps in provision.
Healthy Living Centres (HLCs) are another new initiative, designed to address wider lifestyle issues, such as poor diet and lack of exercise. Again, the idea is that neighbourhoods will tailor the centres to their needs and it's predicted that HLC remit will cover everything from putting on anti-smoking courses to running arts programmes.
As with every other public service, the buzzword in healthcare right now is "joined-up". Some NDC projects are now developing one-stop shops for medical services. West Ham, which suffers from poor transport and outdated facilities, is a prime site. "We want to offer dentistry, pharmacy and GPs surgeries under one roof," says Richard Sharp. "And hopefully, a community bus service in the New Year. What's good about the work we're doing here is that it's focused on what residents really need."
'You don't realise there are choices out there'
Natasha Shepherd was 19 when she had her daughter Chelbie. Natasha is now 26 and seven-year-old Chelbie has been joined by Blaise, 4, and 14-month-old Tyrique. Born and brought up on the Braunstone estate in Leicester the most disadvantaged in the East Midlands Natasha recalls that she was classed as an "old mum" even when Chelbie was born. "Lots of girls round here were having babies at 16 and 17, some younger."
Young women in poor communities are more likely to get pregnant than their more privileged peers. "You don't realise there are choices out there," says Natasha. Although she stresses that she doesn't regret having her children, she does regret missed opportunities. "I was at catering college and would have gone on to university, but I had to drop out when I became pregnant."
Yet Natasha is far from gloomy about her prospects: "Right now, I've got more opportunities than ever." She owes her newfound optimism to the Braunstone Teenage Pregnancy Project. Run by the local women's centre Turning Point, it aims to raise awareness of teenage pregnancy among young people on the estate.
Thanks to New Deal for Communities funding of £44,000 a year, the project can afford to employ a project worker, a consultant, and 10 "peer educators". The latter paid £15 a week so still eligible for benefits are all teenage mothers.
After thorough training, the women visit local schools and deliver presentations to 12- to 16-year-old girls and boys. Topics include the reality of parenting and advice on sexual relationships, including using contraception and resisting pressure to have sex.
Project worker Ruth Epstein stresses that the project doesn't present teenage pregnancy in a wholly negative light. "Being a teenage mother suits some women and we make sure we provide positive images. We educate people to make informed choices."
The project only started in August 2000 so it's early days to gauge whether pregnancy rates are down but anecdotal evidence indicates this is the case.
Just as importantly, the project has boosted both the self-esteem and job prospects of Natasha and her fellow educators.
"When all my children are in school, I'd still like to be a chef," Natasha says, confident that, at just 26, time is on her side. And compared to women in their thirties torn between high-flying careers and having a baby, maybe her choice wasn't so misguided after all.