Speech by the Rt Hon Alan Johnson, MP, Secretary of State for Health, Thursday 7 May 2009: Health Inequalities speech

It is entirely appropriate to talk about health inequalities at an event organised by the Fabians because this year marks the centenary of the publication of Beatrice Webb’s Minority Report on the Poor Law. A report which, inter alia, called for the establishment of the NHS. It is also the 30th anniversary of the completion of Sir Douglas Black’s seminal work on health inequality.

Webb’s Minority Report was a novel and complete departure from the regressive attitudes towards poverty in the latter half of the 19th century, when it was characterised as a voluntary condition caused primarily by failure of character.

The Report’s recommendations have had a profound influence on our society, providing the blueprint for the welfare state as we know and understand it today.  However, it would be, some time before its promise was even partially fulfilled.

It’s as well the Fabians believe in gradualism, because they would have to wait nearly 40 years before the creation of the NHS, and nearly a century before another of Webb’s recommendations, a National Minimum Wage was introduced. They will have to wait a few years more to see the realisation of that other great Fabian campaign, the raising of the education leaving age to 18.

As for the other anniversary, thanks to Douglas Black’s work, 30 years ago, it is now widely acknowledged that the social determinants of poor health have as great an influence as genetics.  As Black pointed out, the evidence is substantial and irrefutable.

Rather like Beatrice Webb’s Minority Report, his investigation, set in train by the  government of Jim Callaghan, had the misfortune to fall on stony ground – in his case, the Thatcher Government of the early 80s, which printed a couple of hundred copies on a Bank Holiday Monday and denied that the social determinants of health even existed.

The link between poor health and deprivation was, for Thatcher, an inconvenient truth, as were the conclusions of Beatrice Webb’s report in 1909.

The price our society has paid for ignoring the Black report is substantial. Under the last Conservative Government the situation actually deteriorated. In the early 1970s, the mortality rate among men from the lowest socio-economic groups was twice as high as those in the top professional groups. By the early 90’s, it was three times higher and by 1997 one in three children were being raised in poverty.

There can be no question about the importance of addressing the wider determinants of poor health today. It has been one of the defining mission of this government.

In 1997, the then Health  Secretary Frank Dobson commissioned Sir Donald Acheson, the former Chief Medical Officer to revisit Black’s report.

His recommendations formed the basis of our programme for action, and the introduction of the first ever target to narrow the health inequality gap by at least 10 per cent by 2010.

Like Black, Acheson identified the fact that success depended not just on better health services, but on many other factors – better housing, increased child benefit, dramatic expansion of access to childcare and pre-school education.

Today’s figures from the Department of Work and Pensions showing the number of households on below average incomes demonstrate that we’re not at the finishing line yet.

But the advances we have made cannot be denied.

In 1998, 3.4 million children were living in absolute poverty. This has now halved. This year, we will introduce legislation to make the eradication of child poverty a legal commitment.

We have invested £21 billion into early years education and childcare, to move us  from the scandal of nursery vouchers to every three and four year old having a guaranteed free nursery place. And we have gone from no Sure Start Children’s Centres in 1997 to over 3000 across the country today. The proportion of people living in poor housing has almost halved.

And the rejuvenation of the NHS means that it can now bring a greater focus to public health and prevention. In 1999, this country spent only 1.9 per cent of total health expenditure on public health, well below the international average. We now spend around 4 per cent – comfortably above the OECD average of 2.8 per cent.

Today, we publish Tackling Health Inequalities, ten years on. It too points to significant progress.

It shows that infant mortality is at its lowest ever level, and it has fallen fastest among routine and manual groups.

Life expectancy has risen by 3 years overall for men and 2.1 years for women. The gains amongst the poorest are proportionally larger that any other groups.

So whilst the gap remains, the health of people in the poorest categories is now at the level of the health of the general population back in 1997 when our quest began – if there hadn’t been such dramatic gains among all social classes, and we’re pleased there has been, the gap would have been eradicated altogether.

The fact that the gap is wider  does not mean that our approach is wrong – indeed, it has been acknowledged that the evidenced-based approach we have taken is leading the way internationally. We now have a strong foundation on which to make further and faster progress.
And the effect of initiatives such as the smokefree legislation introduced in 2007 has yet to be fully reflected in the statistics.

But it does tell us that our efforts must be intensified. To make sure our strategy remains on course for the long term, I asked Professor Sir Michael Marmot, the leading international expert on health inequality, to lead a strategic review of the steps we must take beyond 2010 to narrow the gap even further.

There is much we can do in the short term. It’s not enough to have the right policies and philosophy, if in practice, they are not being implemented effectively in every part of the country. So we are taking further steps to reduce infant mortality by setting up a national support team, which will work in the 43 areas of the country with the highest rates of infant mortality.  

This work is by definition complex and difficult.  Beatrice Webb’s minority report was prescient for many reasons – but perhaps most significantly, because she did not see the poor as a homogeneous group, whose problems could simply be swept off the streets and into the workhouse.

Her Report made its intellectual case through the depth and breadth of its research. But It made its moral case through its stark description of the inhumanity and cruelty of the Victorian Poor Law, with its premise that the able-bodied poor were poor through choice. And therefore by offering relief only in the workhouse, no one would be tempted to “choose” poverty.

The principles of the Minority Report are as relevant to policy-making today as they were a century ago. Two examples stand out in relation to health inequalities.

First, just as people at the beginning of the last century did not choose destitution, so people today do not choose ill-health. People living in the poorest suburbs of London, Manchester or Glasgow do not choose to die 6, 7, 11 or even 28 years earlier than more prosperous neighbours.

Second, the Minority Report called for highly specialised support to help address the very different problems that poor people faced.

Just as Beatrice Webb saw the complexity of poverty, so we have to see the deep and intertwined roots of the causes of poor health. It begins in the womb. Smoking and heavy drinking during pregnancy can lead to low-birth weight babies and a greater risk of infant mortality. Low-birth weight babies are more likely to develop behavioural problems and be poor achievers in school, as well as being more susceptible to further health problems which is why the Health in Pregnancy Grant introduced last month is such an important initiative.

Children living in overcrowded housing are up to ten times more likely to contract meningitis. Those living in damp, mouldy homes are up to three times more likely to have respiratory problems, including asthma. The risk of accidental injury or death is significantly higher for children growing up in poorer families.

Responding to all these issues is no simple matter. It depends on local services – health, housing, education, early years – working together, and above all, being flexible and sensitive enough to accommodate the multiple problems that some families face.

The experience of children with asthma exemplifies this all too clearly. Tuesday was World Asthma Day, highlighting  the fact that this disease affects 5 million people in the UK, including 1.1 million children. It’s one of the major causes of child hospitalisation.

The extent to which asthma can impact on a child's life is not always determined by the severity of the condition, but by the way in which it is managed, both at home, in school, in the community and by local healthcare professionals.

While there is no direct correlation between poverty and asthma, poorer children with asthma are more likely to live in sub-standard housing, in highly polluted areas and to have a parent who smokes – all conditions which trigger attacks.

And if children and their families don't get the help and support to manage their condition properly, then they are more likely to be hospitalised as a result. As the report by Asthma UK shows, those without a personal asthma action plan are four times more likely to have an attack.

Across the country, there are huge variations in how the condition is treated. In some areas, children are 8 times more likely to have to go to A&E because of their asthma.

As Asthma UK’s report also shows, many children with asthma feel excluded because of their condition. 

Some are still told –  even by teachers and parents - that they “can't” do sport, when many of our finest athletes who travelled to Beijing – including Paula Radcliffe, who is probably the greatest female endurance athlete of all time - have asthma.

This approach not only damages their physical health, it impacts on confidence and self-esteem – and in turn, it can lead to bullying and stigma.

So while asthma is a manageable condition for some children in some parts of the country, it is disabling for others, because of where they live and how they are treated.

I very much welcome the work of Asthma UK in expanding their pilots of specialist asthma nurse posts in Dudley and Haringey, which has enabled more schools to develop better policies on asthma, and in the case of Haringey, has dramatically cut the proportion of children with this illness who can’t control their condition, from 54 per cent to 18 per cent.

Along with the work we are pursuing with the Department of Children, Schools and Families to improve support in schools for children with long-term health problems, and the measures we are taking to ensure that every person with asthma has a care plan, I believe the work of Asthma UK will greatly improve the experience of children and young people with asthma.

Asthma is one of many long-term conditions that could be tackled in this way. Where the poor health that results is not just about the condition itself, but the quality of treatment and other social and lifestyle factors.

And where poor health in turn becomes a barrier to achievement and personal fulfilment.

This is why it is absolutely critical that across government, we continue our focus on addressing the wider social determinants of health inequality – this work does not happen on the fringes of policy making, it is intrinsic to everything we do.

Whereas between the 1930s and the 1970s, wealth disparities in developed countries declined dramatically, the 1980s marked the beginning of a dramatic change of course, as social mobility stagnated and gaps between the rich and poor became more sharply pronounced.

Until as recently as 12 years ago, it was acceptable to see such discrepancies as  the price that must be paid for economic success.

This is not the orthodoxy today. What the last 12 years has demonstrated emphatically is that if governments have the ambition and the imagination, they can make a real difference in areas such as child poverty and health inequality. And that this brings net benefits for the whole of society and the economy.

This does not mean that we have achieved everything we aspire to, and it is not to undermine the complexity of deeply entrenched issues such as health inequality.

Progress has been hard-won, and it is still not enough. But we have built a platform for future success, and Sir Michael Marmot’s review will help strengthen our plans further.

Many will wonder whether such ambitions can be retained as the recession deepens. But the lessons of the past are very clear. We ignore the widening health inequality gap at our peril.

The choice we have before us is very simple. We can either take steps to protect people from the worst effects of the global downturn or we can watch from the sidelines as inequalities become more pronounced, and the incredible gains of the last 12 years slowly ebb away.

This is red meat politics, and it’s a contrast that Webb would have recognised. Laissez faire versus intervention. A policy of inaction or active government.

It is telling that while the Conservatives have paid lip service to the importance of investing in public services during the good times, the recession has seen them reverting to their default position of cutting public services at the expense of the most vulnerable in society.
When he became leader, David Cameron wasted no time in casting himself as “Erik” – the Phantom of the Opera. Until now he has been playing the tunes that he thinks the British public wants to hear, seeking to soothe their fears with a bit of easy listening that he hoped would erase the memory of previous Conservative Governments.

But now, just as people have started to move towards him, the mask has been removed, he has changed his tune from “Let the Sun Shine In” to “Don’t They Know It’s The End Of The World”, as the hideous reality of austerity Conservatism materialises. Austerity that is for the many not the few. Certainly not for the 3,000 richest estates in the country, which will receive a £200,000 tax break.

After a long period of political cross dressing, a real choice is emerging between the two main political parties. We remain committed to tackling health and social inequalities, for using investment and growth to restore prosperity. The Conservatives are choosing a different route.

Now is the time for more ambition, not less. As the commentator suggest that moving from a debt ratio of 40 per cent of GDP up to 79 per cent is some kind of apocalypse, It is fitting to remember that the NHS was created at a time when debt was 213 per cent of GDP, because Attlee’s government had the imagination and the courage to look beyond the bleak post-war world in which it was created. We need to be equally courageous today.