Tessa Jowell still has doubts about setting targets on health inequalities, as she told a Manchester conference. Mark Crail joined her on a trip to the North-West frontier

Manchester declared itself the sickness capital of the unhealthiest region of the country last week.

It was a fitting way to greet public health minister Tessa Jowell on her green paper consultation visit to the North West. But it is not the first time health inequalities have been a cause for concern in the city, as regional public health director John Ashton reminded a mixed NHS, local authority and voluntary sector audience.

Flashing a picture of public health pioneer Edwin Chadwick on a screen behind him at a meeting called to hear local views on Our Healthier Nation , he laid claim to a legacy of inter-agency work going back 150 years.

Work across the region to build alliances 'very much echoes the work that was being carried out in the 1840s by political, church and business leaders, and occasionally medical practitioners', he said.

'We have a long history in the North West of tackling public health problems, ' said Professor Ashton. 'But what is a bit sad is that we have lost sight of that in recent decades.'

A report launched by his department set out the challenge ahead: people in the North West live shorter lives, have higher rates of mortality, more limiting long-term illness, and worse unemployment than any other region.

Some public health work even appeared to exacerbate health inequalities, he pointed out: comparing data across a range of measures, it was clear that the people most eager to give up smoking were those in more affluent areas.

Continuing a tour which will take her to every region, Ms Jowell pointed out that the report also showed 'enormous inequalities' within the North West, and warned that national targets alone were not enough.

'It is likely that you will want to identify four or even five other areas on which you intend to focus in order to extend healthy life expectancy in the people you serve, and to close the gap between rich and poor, ' she said.

And she added: 'It is important to realise the sheer scale of the challenge that we have set ourselves.

'Meeting our targets actually means that we have to see a faster rate of improvement in the health of the worst off - those in social classes four and five - than in the overall health of the rest of the population.

'No government has ever succeeded in doing that.'

But she warned against producing 'yet more health education leaflets and campaigns which emphasise the message that looking after your health is your business and if you don't look after your health it is your business'.

She said: 'I don't think there is an enormous amount of point if you live on the fourth floor, on a run-down housing estate, with two small children, being lectured by anybody about the iniquity of smoking in front of your children.

'People know it's harmful. But when your life is full of hopelessness, and you just don't feel you have any control over the situations you face, you do seek comfort in cigarettes.'

The white paper on tobacco planned for later this year would focus on the poor and on children. But the key to success would be to give people back 'a sense of optimism and a sense of control over their own lives'.

The government had set 2010 as the end point for its health targets, 'but I hope we will see progress long before then, ' said Ms Jowell.

'We do intend to publish intermediate targets and we do intend to make sure we monitor year by year the progress that is being made against the overall benchmark target.'

Even so, said Ms Jowell, she had an 'open mind' about whether the public health white paper should set targets to reduce health inequalities, 'because I know how difficult it is to set targets which mean anything at all'.

'If the suggestion is that we set national inequality targets simply to make a strategy appear more convincing and more credible, then it is a bit pointless, ' she argued.

A shorter and less healthy existence Life in the North West is shorter and less healthy than in most other parts of the country, according to Inequalities in Health in the North West, published by the NHS regional office last week.

The North West tops regional league tables for lone-parent households and rates of unemployment. It also has the highest standardised mortality ratio for coronary heart disease and for all causes of death (see table).

Nearly half those over 65 have a limiting long-term illness - more than in any other region. Life expectancy for men of 72.5 years is three years below the best, while for women, at 78, it is the lowest in the country.

But, using 'super profiles', a small-area classification system, public health analysts have been able to show enormous variations within the region - and the correlation between poverty and ill health.

The analysis also shows that health services are not always accessible to, or accessed most by, those who need them most.

The report notes that while the distribution of some procedures is fairly even, 'hip replacements are biased towards the more affluent, and. . . access to angiograms does not reflect the greater level of need in low-income groups'.

Inequalities in Health in the North West. Available from NHS Executive North West, 930-932 Birchwood Boulevard, Millennium Park, Warrington WA3 7QN.