Extract from the Proceedings from a meeting of the Health Equity Network to consider the History of the Black Report published by the Nuffield Trust courtesy of Virginia Berridge London School of Hygiene and Tropical Medicine
Conference and witness seminar
In 1999, the London School of Hygiene and Tropical Medicine held an international conference on inequalities and health (Leon and Walt, 2000). The conference was prefaced by a conference looking at the inequalities issue historically with papers by Roderick Floud, Simon Szreter, Charles Webster and others. The afternoon session was occupied by a ‘witness seminar’, a group exercise in reminiscence, at which we gathered together most of the original members of the Black committee, Sir Douglas Black, Peter Townsend, Jerry Morris, together with David Player and Margaret Whitehead, who had been involved in the follow up report, The Health Divide. There were two professional civil servants, Arthur Buller, who was Chief Scientist at the time, and Elizabeth Shore, the deputy Chief Medical Officer. Jill Turner, the journalist on New Society who originally broke the story of the report’s publication also took part, as did John Fox from the Office of National Statistics.
Participants as follows:
Back row. Left to right: Dr Elizabeth Shore, Professor Margaret Whitehead, Dr David Player, Jill Turner (journalist)
Front row (sitting) Left to right: Professor John Fox, Professor Jerry Morris, Sir Douglas Black, Professor Peter Townsend and Professor Arthur Buller.
Photo: Audio-Visual Department, London School of Hygiene & Tropical Medicine.
Stuart Blume, who had been Scientific Secretary to the committee, was to have been present, but sent a detailed memoir which helped to structure the seminar. Lord Jenkin, Secretary of State in the Conservative government of the time, also sent a memoir based on access to material from his time as a Minister. The full transcript of the seminar, and the papers given at the conference together with some additions, have been published. What follows in this short paper is a distillation from that day of new light shed on the Black Report. I reflect on what this history reveals about the relationship between science, researchers and policy, an issue which has become of more central interest in the intervening twenty years.
The post war context
Charles Webster’s paper on Inequalities as an Issue before Black showed the shape of the issue. Although health inequality had been much discussed by some interests in the pre-World War two period, the coming of the NHS had seemed to offer a new start. Discussion of inequality died away, and key reports, for example Guillebaud, barely mentioned it. The ‘rediscovery of poverty’ came from two directions, from the work of Richard Titmuss and the Child Poverty Action Group, which drew attention in the 1960s to the intractability of inequality. Inequalities in health service provision also began to put the issue back on the agenda. The Resource Allocation Working Party (RAWP) reporting to Barbara Castle and David Owen in 1976, was the service equivalent of the Black Report.
Two well known stories of government reaction; 1980 and 1987
The public story of the government response to Black is well known. The committee was appointed by David Ennals as Labour Secretary of State in 1977, but reported in 1980 to the incoming Conservative government. Publication was on the August Bank Holiday, with 260 copies made available. The consequent media furore was considerable. History repeated itself in 1987, when the Health Education Council’s (HEC) report, The Health Divide, had its official press launch cancelled and rescheduled in a Soho office. This was part of a political reaction to the HEC which saw it transmuted into the Health Education Authority, a special health authority with responsibility for AIDS public education. These events are well known and have been detailed in the combined edition of the two reports.
The 1999 witness seminar: a different picture
The Black Report has enormous symbolism as a case of suppression of a politically sensitive report. The picture which emerged from the witness seminar provided a more nuanced view. It threw light on the process of producing an agreed report and the attendant problems. It was clear that the members of the committee, and two in particular, Peter Townsend and Jerry Morris, had great difficulty in arriving at a consensus on recommendations. Stuart Blume’s memoir shows how the committee moved slowly towards some analysis of existing data and towards agreement on what had to be done. A conference at the King’s Fund in March 1978 added to the complexity. As Blume says, ‘it was not easy to draw conclusions from so wide ranging and so complex a discussion.’ A major issue for discussion also became the resources needed for the broad programme the report began to outline. Could they be freed up by cutting hospital expenditure? This point is taken up in the transcript, where both Jerry Morris and Peter Townsend refer to the disagreement between them on this point and meetings on the fourth floor of the London School of Hygiene and Tropical Medicine to iron out a compromise. Morris and Townsend came from different traditions of inquiry into health – from social medicine and from sociology. Morris refers to this:
“… The way the committee discussed it, it was hospital services. And there developed a major difference of opinion between Peter and myself on this, which you can treat at various levels. At one level is a sort of Isaiah Berlin, two great values colliding which are incomparable, incompatible and you can’t do anything about it…But this was a real difference. The idea that I should in any way support a suggestion that a penny less should go to the hospital services that already were inadequately funded was quite unacceptable…And, it isn’t that, ex-Seebohm and all, I was unaware of the idea of community services, but that was not the point. You can actually have both …”
But this disagreement and delay led to poor political timing – the report was presented to an incoming Conservative government rather than to the Labour government. The medical and scientific civil servants were exasperated at the delay. They were urging the committee on, and, sensing the change in the political wind, wanted something rather than nothing from it. Their focus was on the politically possible rather than the ideal. This exasperation came over clearly in the witness seminar. Elizabeth Shore said:
“I was very aware of the political situation. After all we nearly had a general election the previous autumn. Jim Callaghan, the Prime Minister, gave serious thought to it. I was metaphorically jumping up and down on the sidelines saying, can’t we have some quick and dirty general recommendations to get going on? … The purity can come later on … And I felt very strongly that we had to start doing something at that point without waiting …”
After the Kings Fund meeting, she was in despair. “Were we ever going to get anywhere with the imminent possibility of a government of a very different complexion, a hostility to the working class who seemed to them to be the unions on the warpath again. I just felt we were going backwards.”
Sir Arthur Buller was of a similar view:
“I can recall being urged to ring Douglas to ask ‘How are things going? Can you speed it up?’ Could I ask if the members were conscious of the manifestos of the two major political parties, and whether they had considered these relevant documents? Certainly the Conservatives, in their manifesto, made it absolutely clear that, if elected, they intended to reduce public expenditure … When the final report was produced my personal reaction was, ‘What a time to produce this report’ … You appeared to ignore ‘The Art of the Possible.’”
But Black replied that they were more concerned with getting it absolutely right “with the long term, rather than with any political deadline.” The scientists’ perspective differed from that of the politically aware bureaucrats.
The report was thus presented to a government elected on a platform of reduction of public expenditure. Patrick Jenkin’s memoir stresses the lack of enthusiasm for the report by officials, the resource implications of the recommendations, and advice given by officials about whether or not to publish. The advice he had was to publish in such a way that it clearly distanced the department and government from the conclusions of the report.
“I was initially sceptical about publication. There are many minutes by officials on the files arguing about whether to publish or not, and if to publish, how that might be done. By the time they were able to put a clear departmental view to me on this, they had concluded that the balance of the argument lay with publication, but in a way that clearly distanced the department from the recommendations. Interestingly, the department’s medical advisers were rather less dismissive. They drew attention to a number of the minor recommendations, about better information, improved statistics and more research, and argued that there were certainly issues which should be taken up seriously by the department. They warned that the medical profession would certainly expect to see a proper follow up. The submission to Ministers reached me in May 1980. It reflected the wide ranging criticisms already rehearsed above, and described the report as a mixture of semi digested data and proposals for massive public expenditure. ‘It reads like a policy manifesto from a party who do not expect the responsibilities of office.’”
In another sense, the report’s impact was greater just because of the manner of its publication. John Fox’s recollections showed that it led to an enormous growth of research interest in this area, the growth of networks of researchers, a kind of underground culture of inequalities research and debate which continued throughout the 80s and early 90s. Jerry Morris recalled the great interest shown by the Labour movement, trades councils and so on. This was the background to the re-emergence of the issue in the later years of the Conservative government.
A case study of science, politics and policy
There are a number of ways of interpreting this sequence of events, which also relate to dominant modes of encapsulating the relationship between science, politics and policy. At one level, the story of the Black Report subscribes to a ‘heroes and villains’ view of policy – its symbolic importance as such has been considerable.
There were other examples at the same period of political changeover: the Think Tank Report on alcohol likewise fell foul of political change. Black and its fate can also be seen as rationality thwarted. The ideal of a rational connection between research and policy making is a concept which has lain behind much of the ‘evidence-based movement’, but this is widely criticised in the literature.
The Black episode indicated a complex interaction, from which can be drawn more general conclusions about the operative factors in health and science policy making. Political change was significant, as it was for other areas of health policy making at this time. But the seminar also underlined the close relationships between civil servants and researchers, a ‘policy community’ which operated alongside the political lines of communication. A harbinger for the subsequent history of the science/policy relationship was the key role played in this series of events by the media. Ennals seems in part to have been spurred to action initially through a piece by Richard Wilkinson in New Society. Jill Turner’s expose in the same magazine was important in promulgating the standard view of the report; and David Player played to the media in the set up over The Health Divide. These types of relationships between researchers and research broking mechanisms have become increasingly important since. In being a ‘media event’ the Black report was prescient of future trends. And finally there is the question of timing. As Stuart Blume put it, “that question from 1980 still fascinates me. Why had we failed to agree in time? Is this now, two decades later, a matter for regret?” So far as the growth and consolidation of research into health inequalities was concerned, the Black Report’s ‘non publication’ gave the area a greater impetus for development than it otherwise would have had. Its value as a symbol was considerable while in practical terms its recommendations remained to be implemented.