Category Archives: Equality

‘If livin’ were a thing that money could buy / The rich would live and the poor would die.’  It is, and these lines, from a spiritual temporarily made famous in the 1960s by Joan Baez, remain the best succinct description of the origins of health inequalities.

Occasionally, that reality thrusts itself into the consciousness of the high-income world, as in the case of Hurricane Katrina and the Grenfell Tower disaster.  In the case of Katrina, when the hurricane hit and the levees broke (after years of governmental neglect), evacuation plans presumed that everyone had access to an automobile.  Those who could afford to do so packed up the car and drove to higher ground.  Others, overwhelmingly poor and African-American, were left to fend for themselves as refugees in their own country.  The disposability of certain populations, from the point of view of the powerful, was similarly evident in the case of the Grenfell Tower fire, where local government in an ultra-wealthy London borough appears to have skimped on basic fire protection measures in a social housing block.  Apart from high-profile disasters, the wisdom of the spiritual’s words is evident on a daily basis, although it seldom hits the headlines: in the small city of Stockton-on-Tees in the north of England where I live, differences in male life expectancy between the most and least deprived wards are larger than the national average differences between England and Tanzania.

Life expectancy in Stockton

Outside the high-income world, global health researchers and practitioners constantly confront the realities described in an article on ‘priorities for safe motherhood interventions in resource-scarce settings’.  The authors wrote (in 2010) that the basic interventions recommended by WHO – still far below the standard of care that would be considered normal in the high-income world – would cost US$1.80 per person per year in Uganda, but Uganda was spending only US $0.50 per person on maternal and newborn care.  So, in the health economists’ ubiquitous mantra, priorities must be set.

The researchers who carry out these exercises cannot be faulted, and there is plenty of blame to go around, starting with the fact that a decade later, Uganda’s government was still not meeting  the target of allocating 15 percent of public expenditure to health that was agreed among African Union countries in 2001.  But that is only part of the picture, and it is important to move beyond the familiar vocabulary of resource-scarce settings to ask why some settings are resource-scarce and others not.  Those of us who do so in the academic world are considerably fewer in number than those who take such scarcities as given.  We are not nearly as well funded – the Trades Union Congress and people thrown out of work when transnational corporations relocate contract production from Mexico to China do not fund a lot of research – and (no coincidence) at greater risk of precarious employment.

Nevertheless, we continue to insist that intellectually responsible answers in the global frame of reference must start with colonialism and its legacies.  They must consider more recent historical episodes such as the devastating legacy of structural adjustment programmes that – according to Nobel laureate and former World Bank chief economist Joseph Stiglitz – resulted in ‘a lost quarter-century’ of development in Africa.  A recent study shows that although the World Bank and International Monetary Fund abandoned the vocabulary of structural adjustment around the turn of the century, the relevant practices continue with little change.  Meanwhile, the logic of structural adjustment has been replicated in the decade of (selective) austerity programmes that followed the financial crisis.  Inquiries into the origins of resource scarcity must further consider such factors as the ‘disequalising’ effects of a global economic order that provides abundant opportunities for capital flight, which starves even countries with well intentioned governments of resources needed for health, education, and economic development.

In the contemporary policy environment, one element in particular connects health inequalities around the world:  neoliberalism or, in the words of billionaire investor George Soros (what irony), market fundamentalism. Neoliberalism as a set of norms that guide and justify policy, ultimately equating financial worth with moral worth, conceptually links the dynamics of structural adjustment and capital flight with the fates of the victims in New Orleans and Kensington and Chelsea, and with those of working people quietly living shortened lives of desperation in Stockton-on-Tees (and other deindustrialised communities in the UK, the United States, and elsewhere).  The connections are not only conceptual of course; they are also material and institutional, operating through such channels as campaign money, capital flight and the networks of power and privilege epitomised by the World Economic Forum, where the global super-elite meet to worry about the threat posed to their fortunes by the rest of us.

Daily Mirror cover

Tracing these connections, in contexts half way around the world or as close to home as our local NHS trust in England, is time-consuming and often emotionally draining.  Yet the enterprise is essential to the larger task of demonstrating that neoliberalism is, ultimately and inescapably, deadly – a point clearly understood by at least one media outlet reporting on the Grenfell Tower fire.  Well spotted, say I.

Especially when the context involves social determinants of health, the question of how much evidence suffices to demonstrate this is contested terrain.  Sir Michael Marmot (who chaired the landmark WHO Commission on that topic) and colleagues wrote in 2010 that: ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’.  This is preternatural optimism, as any observer of recent British health inequalities policy will realise, but further discussion must be left for another posting.

This first appeared on the PEAH – Policies for Equitable Access to Health blog

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Income growth in the UK has been weak since the financial crisis. It is a trend which seems likely to continue through to the early 2020s. But in overall terms, this has not been accompanied by a worsening of income inequalities. Official data from the DWP indicate a broad stability in the inequality of disposable household income, equivalised (i.e. weighted) for household composition. In 2006/07, the Gini coefficient before housing costs was 35% and after housing costs it was 39%. In 2015/16, these rates were exactly the same.

Other data published by the ONS actually indicate a slight decrease in income inequality in recent years. According to this data series, the Gini coefficient has fallen from a peak of 36% in 1999-2000, to 35% in 2006-07, to 32% in 2015-16. This is the same level as in 1986, the 1980s being the decade which saw income inequality rise significantly before reaching a plateau in the 1990s.

Britain’s comparative position internationally

According to the standardised data of the OECD, despite a fall in its Gini coefficient from 37% in 2007 to 36% in 2014, the UK is Europe’s most unequal country in terms of disposable income (apart from Estonia). Figures for 2014 (or the latest available) for the other major European countries were: France (29%), Germany (29%), Italy (32.5%), Poland (30%), and Spain (35%). Britain is also the most unequal English-speaking country within the OECD, except the United States.

Contrasting experiences between income and age groups

The ONS figures attribute the marginal reduction of overall income inequality to a rise of incomes of the bottom quintile (the 20% of households with the lowest incomes), and a fall in incomes in the top quintile. The former experienced a rise of £1,600 between 2007/08 and 2015/16 (+13%), while the latter faced a fall of £1,900 (-3%). For all households, the median disposable real income in 2015/16 was £1,000 higher than in 2007/08. According to the Institute for Fiscal Studies, the improvement in low incomes has been due mainly to the performance of the labour market, which experienced strong job growth from late 2013 onwards.

Yet the overall figures mask differences between social groups, especially pensioners and young people. The IFS notes that the median income of the over-60s rose by 11% between 2007-08 and 2014-15. This resulted from an 8% rise in pensioner benefits. But it also stems from real growth in private pensions and increases in employment of older people. In stark contrast, workers aged 22 to 30 have suffered most since the financial crisis: in 2014-15, their real median income was still 7% below the pre-recession level.

Wealth inequality and the impact of housing

Most information about inequality concerns incomes, which are flows and easier to identify. Wealth inequalities by contrast are stocks, and harder to measure. Data are also difficult to come by, as wealth-holders are reticent about declaring their assets. Wealth inequality is, however, a burning issue, as it is far greater than income inequality. According to Rowena Crawford et al., the Gini coefficient of wealth in 2010-12 stood at 64% – nearly twice the income level. Using the latest wave of the Wealth and Assets Survey covering 2010-12, they go on to note that the poorest 1% of households had a net negative wealth of £12,000; the net median wealth was equal to £104,000; while the 95th percentile owned £0.7 million and the top 1% £1.4 million.

In the UK, the question of wealth is particularly important in terms of its impact on housing costs. These tend to aggravate income inequalities as poorer people pay a greater share of their income towards housing. According to DWP data, housing costs have increased the income Gini coefficient by an average 4% since the mid-1990s.

Trends in poverty

The latest figures indicate that median equivalised net disposable income before housing costs in the UK was £481 per week in 2015/16. Taking the 60% threshold of median income as a measure of poverty, the poverty income was thus £288. Respective weekly amounts after housing costs were £413 and £248.

Accordingly, there were 10.4 million people living in relative poverty before housing costs in 2015/16, equal to 16% of the population. After housing costs, these figures rise to 12.8 million. Notably, there has been a slight decline in the last two decades. In 1994/95, 19% of the population was living below the 60% threshold before housing costs; in 2006/07 the figure was 18%. The after housing costs numbers were 24% and 22%.

An alternative measure of poverty shows a greater absolute improvement. When taking the nominal value of the 60% income threshold in 2010/11 and adjusting it for inflation, the number of people living at or below this real level of income after housing costs fell from 41% of the population in 1994/95, to 22% in 2006/07, to 20% in 2015/16.

Future trends and Brexit

While it is still too early to measure the impact of Brexit on inequality and poverty statistics, both the IFS and the Resolution Foundation published studies suggesting that the diverging experiences of pensioners and young people are likely to persist in the medium term. The Resolution Foundation study indicates that higher inflation following the devaluation of the pound will squeeze real incomes, especially for poorer households, while the IFS estimates that earnings growth will favour higher incomes. At the same time, low-income private renters are likely to be hit especially through to the early 2020s.

First published on the British Politics and Policy blog

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Evidence and policy priorities

There are stark ethnic inequalities in health: Black Caribbean, Pakistani, and Bangladeshi people have between six and nine fewer years of disability-free life expectancy than do White British people

Ethnic Minority health

How do we understand this diversity?

Making sense of ethnic inequalities in health – The epidemiological method

‘Epidemiology is the study of the distribution and determinants of disease. The main method of study, particularly for investigating the causes of disease, is to compare populations with different risks of disease. Ethnicity is a variable that is used increasingly to define populations for epidemiological studies.’

Senior and Bhopal (1994)

  • But this encourages an unreflexive and uncritical use of the concept of ethnicity. Ethnic groups are treated as pre-constituted entities with pre-specified properties, with an emphasis on the different/exotic.
  • Explanations are then ‘read’ from the ethnic and disease categories available in data. The presumed properties of ethnic groups, be they cultural or genetic, become the source of explanation for the disease outcome.
  • Rather, we need an approach that pays attention to the processes that lead to the construction and racialisation of ethnic identities, and how these processes shape life chances – what might be called fundamental causes.

Ethnicity, social relationships and social structure

Racial and ethnic groups … are discursive formations, calling into being a language through which differences are accorded social significance, and by which they may be named and explained. What is of importance for social researchers studying race and ethnicity is that such ideas also carry with them material consequences for those who are embraced by them and those who are excluded from them.

Solomos (1998)

The ways in which identities are perceived, valued, mobilised and interacted with are shaped by economic, cultural, legal, political and symbolic resources. Important here is how emotions are attached to symbolic resources, emotions around risk, danger, fear and disgust, which then shape the practices of individuals and institutions. ‘Racial life [is] suffused with shared passions, imageries and fantasies’.

Emirbayer and Desmond 2015

Racism as the fundamental cause

  • Racism has its origins in ongoing historically determined systems of domination that serve to marginalise groups on the base of phenotypic, cultural or symbolic characteristics, thereby generating a racialised social order.
  • Explanation, then, needs to examine the role of three inter-related dimensions of racism – structural, interpersonal and institutional.
  • Structural racism is reflected in disadvantage in access to economic, physical and social resources. This does not have just material implications, but also cultural and ideological dimensions, material inequality justified through symbolic denigration.
  • Interpersonal racism (ranging from everyday slights, through discrimination, to verbal and physical aggression) is a form of violence/trauma and emphasises the devalued status of both those who are directly targeted and those who have similarly racialised identities, thereby engendering meaningful psychosocial stress.
  • Institutional racism (first coined by Carmichael and Hamilton 1967) is reflected in routine processes and procedures that translate into actions that shape the experiences of racialised groups within these institutions.
  • These disadvantages, accumulating across a life course, are the drivers of ethnic inequalities in health outcomes.
Ethnic differences in household income

Ethnic differences in equivalised household income

Low birth weight by occupational class

Low birth weight by occupational class

Standardising for socioeconomic position:

Standardising for socioeconomic position

This reflects both the particular economic location of ethnic minority groups and the multi-dimensional nature of the economic and social inequalities they face, meaning that no realistic statistical adjustment can plausibly simulate randomisation.

Racialised socioeconomic inequalities mean:

  • Lower incomes;
  • Lower status occupations;
  • Poorer employment conditions;
  • Higher rates of unemployment and longer periods of unemployment;
  • Poorer educational outcomes;
  • Concentrated in economically and environmentally depressed areas (but positive effects of ethnic density);
  • Housing tenure;
  • Poorer quality and more overcrowded accommodation.
  • And inequalities that accumulate across the life course and across generations.
Persisting ethnic inequalities in unemployment

Persisting ethnic inequalities in unemployment 1991-2001-2011

Experiences of racism and discrimination:

  • One in eight ethnic minority people experience racial harassment in a year.
  • Repeated racial harassment is a common experience.
  • 25% of ethnic minority people say they are fearful of racial harassment.
  • 20% of ethnic minority people report being refused a job for racial reasons, and almost three-quarters of them say it has happened more than once.
  • 20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
  • White people freely report their own prejudice:
    • One in four say they are prejudiced against Asian people;
    • One in five say they are prejudiced against Caribbean people.

Research across outcomes and contexts consistently shows the adverse impact of racism on health (for example, Wallace et al. 2016

Racism, discrimination and health:

Changes in levels of racism

Changes in levels of racism 1993-2009

Persisting prevalence of racial prejudice

Persisting prevalence of racial prejudice 1983-2013

Institutional racism in health services?

Access to and outcomes of care:

  • No inequalities in access to GP services.
  • No inequalities in outcomes of care for conditions that are largely managed in primary care settings:
    • Hypertension, raised cholesterol and, probably, diabetes.
  • The effect of healthcare systems – a health service with universal access and standardised treatment protocols?
  • Marked inequalities in access to dental services.
  • And marked inequalities in the US insurance based system.
  • And institutional racism evident in some areas:
  • Some inequalities in access to hospital services.
  • Ethnic inequalities in reported levels of satisfaction with care received.
  • And, mental illness and psychiatric services …


  • Racisms are fundamental drivers of observed ethnic inequalities in health.
  • In investigating this, it is important to examine the ways in which structural, interpersonal and institutional racisms operate and constitute one another.
  • Structural conditions of socioeconomic disadvantage and interpersonal experiences of racism both create an increased risk of poor health for ethnic minority people.
  • They also shape encounters with institutions that have policies and practices that lead to unequal outcomes – education, employment, housing, criminal justice, politics, etc., as well as health and social care.
  • Institutional settings represent sites where we see the concentration and mediation of structural forms of disadvantage and interpersonal racism. This is produced via both the unwitting practices and overt agency of individuals operating within particular structural conditions.
  • Institutional racism will take different forms, will operate differently, across institutions with a different focus – for example, the functions of institutions dealing with cancer screening compared with those implementing coercive treatments for severe mental illness.

Reflecting on Policy

  • There has been little development of policy to specifically address ethnic inequalities in health, only occasional, limited and local intervention, with no real evaluation of the impact of specific or general policy on ethnic inequalities in health.
  • For example, a shocking neglect of ethnic inequality in the Marmot Review – assumption that socioeconomic inequalities are unimportant for ethnic inequalities in health, or that general policies to address questions of equity will also address ethnic inequalities.
  • But not a policy vacuum, there are clear policies around identity, culture, community, segregation and migration, all of which are likely to negatively impact on ethnic inequalities in health.
  • And ethnic minority people have been disproportionately impacted on by public sector retrenchment (austerity measures).
  • In fact, the evidence base strongly suggests that policy development should focus on the social and economic inequalities faced by ethnic minority people.
  • Need short term policies to address economic inequality (tax, employment, welfare, housing, etc.).
  • However, the economic inequalities faced by ethnic minority people cannot be addressed by policies targeted at on average reductions in economic inequalities, because such policies don’t address processes impacting on ethnic minority people – reflected in institutional practices.
  • Example: early years investments, which don’t address the emergence and persistence of racial disadvantage in the education system and labour market.
  • Example: failure of favoured ‘up-stream’ interventions, such as SureStart, to engage with and meet the needs of ethnic minority groups.
  • Example: public sector workers bearing the cost of the recession.
  • Example: rise in part-time work and zero hours contracts.
  • Rather need long-term policies that promote equitable life chances and that address racism and the marginalisation of ethnic minority people – a focus on institutions, including politics and Government, is crucial.

Institutional reform: an example

  • As an employer, the public sector has the opportunity to provide significant leadership.
  • For example, in 2017 the NHS directly employed 1.2 million people, indirectly many more, so employment practices within the NHS are able to impact on the labour market nationally and regionally.
  • Ethnic minority people are over-represented in the NHS (and public sector) workforce – 22 per cent of NHS staff are not White, compared with 13 per cent of all workers.
  • Discussion around public sector employment has focussed on enhancing efficiency by reducing labour costs, consequently opening up opportunities for private investment.
  • Instead could use this as an opportunity to implement positive and equitable employment practices, setting a standard: employment rights, holidays, sick leave, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights.
  • Such changes are likely to mostly benefit those in lower employment grades and more precarious employment conditions – ethnic minority workers.
  • Could also address the marked ethnic inequalities within the public sector workforce – ‘snowy white peaks’ – rethinking institutional structures and practices, and addressihng pay differentials.
  • Reforming institutional cultures – the whiteness of institutions – and addressing discrimination and racism in the workplace.

This was presented at our conference Public Health Priorities for Labour

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Labour’s Health Inequalities strategy had some success

Trends in life expectancy

Trends in life expectancy in the most deprived Local Authorities and the rest of England and the absolute difference 1983-2015.

What can we learn from the experience of the programme?

Good points:

  • Cross government
  • increase in equitable investment.
  • Progress on child and pensioner poverty.
  • Technical support for local action.

Bad points

  • Top down.
  • Ignored mental health inequalities.
  • Didn’t address income inequalities, disability poverty.
  • Didn’t empower disadvantaged communities

Priority 1.

Ensure resources for health are distributed to reduce inequalities in life chances between places.

Experience of getting the resources to the right places:

NHS & Local Authority funding per head

NHS & Local Authority funding per head 2002-2016

Funding in London

London does better than the rest of England

What was the impact of the NHS resource allocation policy from 2001 to 2011?

Cuts in council budgets

Cuts in council budgets 2010-2015

  • Review and simplify current systems for allocation of public resources to local areas.
  • Reinstate health inequalities objective for the NHS resource allocation policy.
  • Make reducing inequalities an explicit objective of local government and education allocation formulae.
  • Progressively shifting more resources to disadvantaged places.

Priority 2.

Devolve power – increasing the influence that the public has over how resources are used.

The Devolution Deception

The Devolution Deception

Radical devolution

Priority 3.

Increase the public health benefits of the social security system.

Public Health Toolkit

The benefits budget is twice as big as the health budget

Who gained most….

Poverty trends 1994-2014

This 10 year rise in absolute poverty is unprecedented since records began

  • Prioritize reducing child and disability poverty.
  • Ensure benefit payments provide an adequate income for healthy living.
  • Ensure the benefit processes is supportive and treats people with respect.
  • Reduce conditionality and sanctions.
  • Evaluate the health impact of any changes to the benefits system.

Priority 4.

Develop universal, comprehensive, high-quality early Childhood care and Education.

  • Extend the 30 free hours to all two-year-olds.
  • Provide affordable high-quality childcare through direct government subsidy.
  • Progressive investment to ensure that the places exist to meet demand.
  • Transition to a qualified, graduate-led workforce, by increasing staff wages and enhancing training opportunities.
  • Extending maternity pay to 12 months
  • Halt the closures and increase the amount of money available for Sure Start

So my 4 Priorities for Health Inequalities:

1.Ensure resources for health are distributed to reduce inequalities in life chances between places.

2.Devolve power – increasing the influence that the public has over how resources are used.

3.Increase the public health benefits of the social security system

4.Develop universal, comprehensive, high-quality early Childhood Care and Education.

national health inequalities strategy

and Re-establish a national health inequalities strategy.

This was presented at our conference Public Health Priorities for Labour




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“Almost every day now the media carries stories about inequality and its effects.

In the past few weeks, the Department for Health has confirmed that the health gap between rich and poor in England is growing.

Reports by Lloyds Bank and the Social Market Foundation have drawn attention to our disparities in wealth, with a tenth of adults owning half of the country’s wealth while 15% own nothing or have negative wealth.

Respected independent ‘thinktanks’ like the Institute for Fiscal Studies and the Resolution Foundation have repeated their warnings that, at a time when wages generally are only growing slowly, the combination of tax cuts and cuts in welfare benefits means that income inequality will increase further over the next few years.

“Economic inequality has increased in nearly every advanced Western country…”

This is not just an English or British issue. In March, International Monetary Fund (IMF) researchers estimated that the US economy had lost a year of consumption growth because of increased income polarisation. And of course inequality was a major factor in the Brexit vote and in the election of President Trump.

My interest in the subject was first aroused by my work on the introduction of markets into higher education. I found that the associated increase in competition through mechanisms like tuition fees had exacerbated the inequalities between universities and the constituencies they serve, without any significant compensating benefits. This led me to wonder if there might be parallels in the economy and society more generally.

What I established was that economic inequality has increased in nearly every advanced Western country over the past thirty or so years, and that this has led to a huge range of costs and detriments. Moreover, these costs and detriments are not only social. As the IMF research confirms, increased economic inequality has an economic cost as well. Above all, growing inequality is disabling democratic politics as the concentration of economic power is increasingly reflected in a concentration of political power (as can be seen most clearly in the US).

economic inequality

“Growing inequality is disabling democratic politics…”

But whilst nearly everyone agrees that – to paraphrase Dunning’s famous 1780 Parliamentary motion, economic inequality has increased, is increasing, and ought to be reduced – there is no agreement on how this should be done.

Broadly speaking, there are two schools of thought:

One – the ‘market’ view – is that increased inequality is the inevitable outcome of underlying structural developments such as globalisation, skill-biased technological change, and financialisation (the growing economic role of such processes as banking and securities trading) over which individual countries and governments have little control. These changes are leading to what have been termed ‘winner-take-all’ markets where those at the top gain rewards out of all proportion to their contribution to society.

The alternative, ‘institutional’, theory is that it is due to the political choices made in individual countries, and especially the neoliberal policies of deregulation, privatisation, tax reductions, welfare cutbacks and deflation pursued in most Western countries since the mid- to late-70s, but particularly associated with Margaret Thatcher and Ronald Reagan.

I believe that it is the combination of these underlying structural developments with those neoliberal policies that has driven the post-80s rise in inequality, with the US and Britain well above the other wealthy Western countries in the extent to which inequality has grown there over that period.

So the key to reversing, halting or slowing inequality lies in the first place in reversing these neoliberal policies, but without losing the benefits of properly regulated market competition in sectors where it is appropriate.

The following is a short list of measures that would start to reverse inequality in Britain:

  1. Require the potential impact on inequality to be a major test of every other policy or programme introduced by the Government.
  2. Show that we are serious about tax avoidance by reversing the long-term decline in the number of professional HMRC officials.
  3. Progressively adjust the balance between direct and indirect taxation (VAT), increasing the former and reducing the latter.
  4. Increase the income tax rates for higher earners (say, above £60,000).
  5. Introduce some form of wealth tax.
  6. Begin the rehabilitation of the trade unions by repealing most of the 2016 Trade Union Act.
  7. Reverse the cuts in welfare benefits made by the Coalition and Cameron Governments.
  8. Introduce measures that really will force companies to take account of interests wider than those of top management.
  9. Begin to end segregation in education by removing the charitable status of the private schools.
  10. Focus macroeconomic policy on demand and wage growth rather than inflation and corporate profits.

The Labour election manifesto has some proposals on these lines, but no political party has yet really got its mind round the full range of measures that are needed to combat inequality.

Until they do, inequality will continue to increase.

This was first published on the Policy Press blog

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Poverty in the UK is a serious problem, and it is a problem that is often ignored or wilfully misrepresented in political debate. Social injustice is wrong, but misrepresenting the nature of social justice is doubly wrong, because it encourages further injustice.

Of course there are natural and selfish reasons why we may all want to misunderstand the nature of justice, and usually such misunderstandings start by distorting a half-truth rather than deploying a lie. In the UK a common distortion starts with a twin pair of assumptions that are not exactly false, but are highly misleading:

  • Economic development requires freedom of exchange, or what is often called ‘the market,’ the freedom to buy and sell with flexible pricing. For most of us this means the freedom to buy things that others sell us and the freedom to sell our labour, by becoming an employee (or servant) of another person or organisation
  • When we freely enter into contracts with other people or organisations then we are bound by our promises. If we behave properly and follow the agreed rules, even if we end up poorer, it might still be said that we were treated fairly.

The first assumption is utilitarian. It is claimed the free market exists to serve the overall good; and there are good reasons to believe that markets can sometimes perform a useful social function. The second assumption is deontological. We are free to make our own decisions and promises, but we must accept the results of those decisions, even if other people seem to be doing better than us. In the UK people who believe strongly in these two assumptions, like the philosopher John Stuart Mill, are called liberals (although confusingly the term liberal means something very different in the USA).

Liberalism is a great philosophy, if you are wealthy, because it offers you a double comfort: Not only are you entitled to whatever you’ve got, but you can also persuade yourself that you are part of a system that is good for everyone (in the long-run).

However it does not take much imagination to realise that this cannot be the whole story. For injustice is a logical consequence of unrestrained economic freedom, and in every decent society there have always been systems, rules or institutions that are designed to reduce the injustices created by economic freedom.

Just think about what happens if we simply allowed people absolute economic freedom. First, those people who are more successful will, over time, may use their economic power to guarantee their own future success and so will make it harder for others to compete. This is why democratic governments tend to restrict monopolies or replace monopolies with nationalised industries, like the NHS, which work for everyone’s benefit. It is also why public education and free university education matter, because it reduces the advantage the better-off can buy for their children.

Second, people who lose out will become more desperate, unable to sell their labour for income or only able to sell it at a very low price. This is why democratic government’s have been forced to both set minimum wages and to create income security systems to redistribute money towards the poorer half of the population.

There is nothing in a free economic market that ensures that you will get a fair, reasonable or even adequate price for your labour. That’s not how markets work. If you are very poor then you must be prepared to sell your time for next to nothing. Economic freedom has never naturally protected the interests of the poorest, the weakest or those without power. Instead it often releases the very worst in our nature: greed, avarice, pride and the sadistic pleasure of exploitation.

These statements should not seem controversial or challenging. They represent some of the hard-won lessons of the twentieth-century, a century which proved that the price we can pay for ignoring social injustice is revolution, war, terror and Holocaust. So, it may seem surprising that, in the early years of the twenty-first century, we seem to be in danger of forgetting all these important lessons. Not only do the half-truths of liberalism seem to be back in fashion, but many are even tempted to go a little further and embrace some utterly false beliefs:

  • Poverty is just a matter of perspective, it’s all just relative, and the poorest even benefit from inequality, because inequality is a natural part of a free economic system. What really matters is economic growth, not the distribution of that wealth.
  • People who are not doing as well as you deserve to be poor, just as you deserve to be rich. In fact, economic success means you are a better person and economic failure means you are an inferior person. It is perhaps even dangerous to protect the poorest as this might encourage the wrong kind of people.

I think it is obvious that these beliefs are false; and I think it is also obvious why they are tempting. This kind of thinking is no longer liberal, it is much closer to fascism or eugenics. It pictures some humans as more valuable, more productive, more equal than other humans. Dog-eat-dog economic freedom is twisted into an engine for human improvement. I think it is this kind of extreme liberalism that is sometimes called neoliberalism.

It is also fascinating (in a rather horrible way) to see how the rather different idea of meritocracy has increasingly been promoted as if it offers a positive vision for society. This is peculiar in the extreme. Meritocracy means that ‘the best’ people should have the most power (and, it is typically assumed, the most money). In fact the term meritocracy is simply a modernised form of aristocracy – ‘aristos’ being the Greek word for the ‘the best’. The difference is that the best is now presumed to be some cocktail of ‘the clever,’ ‘the powerful’ and ‘the rich’ – rather than landed nobles.

Old-fashioned liberalism was often combined with a commitment to charitable action: We have other obligations beyond keeping our promises, and any financial success should bring extra social responsibilities, much in the same was that old-fashioned aristocrats used to believe that they had extra responsibilities to the commoners – “noblesse oblige”. It was for this reason that many of the early pioneers of capitalism (Rockefeller, Carnegie, Harkness etc.) actually did spend much of their money on works of public philanthropy.

However, today’s neoliberals and their meritocratic cousins seem much less interested in social or moral responsibility. Success is not an invitation to exercise social responsibility, it is merely the proclamation of the right of the powerful and rich to seek even higher rewards for themselves, and to look down their noses on those with less money or with different gifts. Liberalism and meritocracy merely justify growing injustice: encouraging the powerful to believe they are entitled to more money; encouraging the wealthy to believe they are entitled to more power. As shallow philosophies go we are scraping the bottom of a very deep barrel.

How did we get here?

How have we got here? How have we forgotten the lessons of the past? Why do we even begin to treat these crazy and wicked views as somehow reasonable points of view. Although I am a Christian I do not believe that declining faith or moral standards is the best explanation. In fact countries like the USA, which have a very high rate of Church attendance, also seem to be just as morally confused as the agnostic UK. We will find better explanations I think if we look at the economic, social and political characteristics of our society.

I also think that, despite the fact that things are currently getting worse, there are several reasons to be hopeful. Social and economic changes are themselves driving us towards a crisis point that might ultimately be very helpful, although how quickly this change will take place is unclear. Although the rise of liberal and meritocratic thinking is a growing threat, I think there remains a stubborn awareness of older truths that hard to dislodge from the human soul:

Justice lives in poverty.
She survives.
She measures
What is necessary.
She honours what ought to be honoured.
She seeks out clean hearts, clean hands.
She knows what wealth and power
Grind to dust between them.
She knows
Goodness and the laws of heaven.

Aeschylus: Agamemnon

In fact, even when our leaders try to exploit liberal and meritocratic prejudices they can only go so far, and often they try to manipulate language and statistics in order to cover their tracks. This tells us that not all hope is lost; there is no need for deception if all truth is gone.

What we find in practice is that modern politics is a little like street magic. The performer wants us to look in one place, while what is really important is happening somewhere else. In fact I think we can spot at least 10 myths that are commonly exploited to put our moral conscience to sleep:

  1. Inequality is good for the economy
  2. Growth is good for everyone
  3. The welfare state protects the poorest
  4. The rich pay the highest taxes
  5. Only the poor need benefits
  6. Benefits are often claimed fraudulently
  7. People are too dependent on benefits
  8. The benefit system is too expensive
  9. Government has tried to protect the most vulnerable
  10. There is no real poverty in the UK

I want to use this essay to not only challenge these myths, but more importantly to try and show how the use of these myths performs a useful social function for the political system. Ultimately I believe that, for all the worthy discussion about poverty reduction in the UK (from across the political spectrum) there has been no meaningful commitment to reduce poverty for over 40 years. This means that those of us who care about equality and social justice may need to think differently about our goals and our strategies.

1. Inequality is not good for the economy

Liberals will often argue that inequality is a natural part of the economic order and that if we want the benefits of a developing free-market economy then we must accept that inequality will naturally arise. Moreover they also argue that interfering with the labour market will have negative consequences. However, as Figure 1 show, if we look at the growth rate in the UK it has not increased as the UK has become a more unequal country, if anything it has declined.

Figure 1. UK Economic Growth Rate 1949-2012

In fact inequality has not benefited the economy and there are many ways of combining economic freedoms with social justice, primarily through redistribution and other social and economic policies.

2. Growth is not good for everyone

Another common proposition is that we should not care about equality, just about growth. If an economic policy raises the standard of living of everyone then the fact that some people benefit more is irrelevant. But, as we have seen, the opposite is true – inequality seem to reduce growth. So what we should really pay attention to is who does benefit from economic growth.

The following data is all taken from the Office for National Statistics, who publish detailed information on the family (household) incomes for every year from 1977 onwards. This allows us to compare how the incomes of different groups changed between 1977 and 2014. We can compare and contrast these incomes more effectively by bring them into line with the values for 2014. Figure 2 shows how incomes had changed – before any redistribution by tax or benefits – between 1977 and 2014. I have adjusted the data from 1977 to bring it in line with the data from 2014 by showing how income distribution for households would look if 1977 had the same average household income as households did in 2014.

We can see that relatively only the top 20% of families have really benefited from economic change during this period (although there is also a tiny uplift for those in the second decile). So, broadly, we can see:

  • the poor have got poorer
  • the rich have got richer
  • the middle has got a lot poorer

Figure 2. Comparing Distribution of Original Incomes 1977-2014

So, during the post-1977 period growth has declined (as per Figure 1) and economy has skewed the benefits of that reduced growth to the better off. This means the poorest are losing twice: lower growth and higher inequality.

3. The welfare state is not protecting the poorest

It is often assumed that the welfare state almost automatically benefits the poorest most. However, as we shall see, the reality of the welfare system is not quite what people believe. The welfare state’s primary direct impact comes in three forms:

  • benefits – increased income
  • taxes – reduced income
  • services – increased income for its employees, reduced costs for those with needs

Now if we compare the incomes after taxes and benefits between 1977 and 2014 as we do in Figure 3 we can see that, rather than increasing the incomes of the poorest, the system’s function has been to increase the incomes of middle-earners.

Figure 3. Comparing Post-Tax-Benefit Incomes 1977-2014

This means that we should be very careful to examine two very different kinds of impact on family income. Some of these changes seem to be economic. We can see a significant drop in the incomes of almost all groups, except the wealthiest 20%. However we can also see that tax-benefit policy during this period has been engineered to bring about changes that are just as significant as the economic changes. In fact it looks very much like, as the economy has depressed middle-incomes so the tax-benefit system has been used to reflate them.

Because the poor were already so poor and the rich were already so rich the changes are best understood using percentages and ratios. So here are some key facts:

  • Before tax and benefits the income of the richest 10% was 18 times higher in 1977 and 27 times higher in 2014.
  • After tax and benefits the income of the richest 10% was 7 times higher in 1977 and 13 times higher in 2014.
  • Economic changes reduced the income of the poorest 10% by 15% between 1997 and 2014
  • Policy changes reduced the income of the poorest 10% by 26%
  • Middle income groups all lost income because of economic changes, the most extreme group being the 4th decile, who saw their income reduce by 29%
  • However middle income groups saw their incomes increase because of policy changes that increased their benefits and reduced their taxes, with the 4th decile benefiting by a 26% increase in their income
  • The rich saw a huge growth in their income of 31%, but a modest reduction by policy of only 8%

It is these facts that explain the focus by politicians on the ‘squeezed middle.’ However it is not that the middle has been squeezed by the poor or by economic policies that support the welfare state. Instead most of the tax-benefit system is focused on increasing the incomes of those in the middle. In fact as we can see in Figure 4 and Figure 5, between 1977 and 2014 income has been taken off the poorest and redistributed towards the middle.

Figure 4. Changes in income for families 1977-2014

Figure 5. Percent changes in income for families 1977-2014

What is really going on is a fundamental change in the structure of the economy. Growth continues, but the beneficiaries of growth are getting fewer – basically only the top 20%. The welfare system is not primarily being used to benefit the poorest, it is primarily organised to support the middle.

4. The poor pay the highest taxes

One of the biggest deceptions of everyday political rhetoric is the use of the term ‘taxpayer.’ The term is often used to imply that there is some group, the better-off, who are somehow contributing the most, and that the poorest are in someway not taxpayers. This deception relies on pretending that the only significant tax is income tax – but this not true. Income tax is the biggest tax the richest pay, but for others indirect taxes, like VAT, are much more important.

For the following figures I have primarily used the latest ONS data (ONS, 2017). So, if we take all the taxes people pay, and then compare it to their total income then the group that pays the highest rate of tax is the poorest 10% of families – who pay more than 10% more in tax than any other group.

Figure 6. Overall rate of tax paid by household

The reason for this is that the UK tax system is regressive – which means it hurts the poorest most – because it relies to such a high degree on indirect taxes, taxes on spending, not on income. Figure 7 compares the detailed breakdown of taxes paid between the poorest 10% and the richest 10%.

Figure 7. Comparing the different taxes paid

5. We’re all on benefits

A similar deception is that only the poor are ‘on benefits.’ Nothing could be further from the truth. Every group benefits from benefits and the poorest do not even benefit the most. In fact it would truer to say that we’re all on benefits and that the primary beneficiary of benefits is the middle-income earner. However this deception is maintained by treating some benefits, like tax credits and pensions, as if they are not really ‘benefits.’ This serves to aid the natural desire of the better-off to see themselves as somehow distinct from those relying on Job Seekers Allowance or Employment and Support Allowance.

Figure 8. Distribution of benefits across different income groups

6. Benefit fraud is utterly insignificant

Another common lie is that benefit fraud is a significant problem. In fact, benefit fraud is very low indeed. It is dwarfed by tax fraud and even more by tax avoidance (the legal but immoral effort to avoid your social responsibilities). The fact that the public seem to believe benefit fraud is so much greater must have something to do with the way in which politicians and the media have exploited an image of some people in society as being somehow particularly unworthy. This problem certainly began before Austerity as it was the new Labour Government who launched the ‘Benefit Thieves’ campaign which pandered to this non-existent social problem.

Figure 9. Benefit fraud in context

One very striking statistic is that the poorest not only pay lots of tax, mostly indirect taxes like VAT, but they also pay a significant level of income tax. This is surprising because their incomes are so low they should not be paying any income tax. However, the poor have no accountants, and I suspect that the application of emergency tax rates for short-term work means that the government is actually defrauding the poorest by over-taxing them. In addition the £17 billion of unclaimed benefits could also be treated as a form of government fraud – creating a system so complex – no one knows what they’re entitled to.

What we must ask is who benefits from this kind of rhetoric. It certainly provides a useful distraction from the real issues, including growing inequality. Perhaps there is a sense in which this is a further price of a declining middle-class. As incomes drop, status is threatened. Perhaps, as well as propping their income through tax and benefit changes politicians are pandering to the need of middle-income earners to feel morally superior to those who are poorer. I suspect the negative skiver, scrounger, fraudster rhetoric is really the mirror image of the as ‘hard-working families’ ‘the squeezed middle’ or ‘alarm-clock Britain’. The rhetorical purpose is to divide us and delude us. Money is transferred from the poor to the middle, but stigma is added to the poor to make the middle feel less bad about this act of theft.

7. People are not too dependent on benefits

Another common fallacy is that the benefit system is primarily about supporting people who are out of work and that benefits need to be low in order to discourage people from becoming dependent upon them. But even a cursory glance at benefit spending destroys that myth.

Figure 10. Different benefits used

Job Seekers Allowance (the UK’s unemployment benefit) represents 0.7% of total spending. Whereas the four main benefits (nearly 80% of the benefit bill) are not even really directed to address poverty at all:

  • 48.3% on pensions – a basic income for all people of retirement age
  • 12.4% on housing and council tax benefits – compensation for the unequal distribution of property
  • 11.1% on tax credits – compensation for the collapse of middle-income wages
  • 6.2% on child benefit – a basic income for nearly all children

The poor are in no danger of becoming over-dependent on benefits. Instead the whole of economy is dependent on a significant level of income redistribution and social security simply to function. The shame is that the poorest are treated so poorly by that system – stigmatised and impoverished.

8. The benefit system is inexpensive

The UK’s spending on the welfare state is higher than some countries and lower than others. It has remained at a fairly constant level over a long period. There is no reason to think that welfare spending is unsustainable; it is only unsustainable if we refuse to pay for what we think is necessary, and this just requires us to adjust taxation levels. Politicians like to pretend that there is some crisis in order to justify policies they believe will bring them electoral advantage. We should ignore them.

Figure 11. Government spending over time

Often it is spending on benefits that is represented as the greatest and most unsustainable cost for the welfare state. What is more it is claimed that the poorest may have become dependent on these benefits and that cuts in services or income are necessary to get people ‘off benefits’ and into work. In fact the truth is much more interesting.

First of all, as we have already seen in Figure 6, the cost of benefits is hugely exaggerated by ignoring the fact that most benefits are paid straight back in taxes. If we calculate the net or real cost of benefits – after taxes we find that the cost of benefits is very low indeed: £27.8 billion or 1.4% of GDP.

Figure 12. The real cost of benefits

Benefits are not even strictly government spending, they are a transfer payment, reducing one person’s income through taxes and increasing another with a benefit. The fact that benefits are presented as government spending is really just a trick of accountancy. If instead we accepted that redistribution was an essential feature of a modern economy we would distinguish it much more clearly from public spending, such as the NHS and education. Currently we’ve got things the wrong way round; we treat redistribution as a somewhat dubious feature of the welfare state, rather than as its primary function.

9. Government often attacks the most vulnerable

A further rhetorical trope, that turns out to be a lie, is the idea that government will naturally and quite properly protect those in most need. This line has been particularly important during the Austerity period, although it is not an uncommon lie at the best of times. For instance, I have explored elsewhere, and at some length, how austerity policies targeted those on low incomes, and in particular disabled people with the greatest need. The UK Government’s policies have been so shameful in this regard that the United Nations has openly criticised the UK for failing to meet its human rights obligations:

“The Committee is seriously concerned about the disproportionate adverse impact that austerity measures, introduced since 2010, are having on the enjoyment of economic, social and cultural rights by disadvantaged and marginalised individuals and groups. The Committee is concerned that the State party has not undertaken a comprehensive assessment of the cumulative impact of such measures on the realisation of economic, social and cultural rights, in a way that is recognised by civil society and national independent monitoring mechanisms (art. 2, para. 1).”

UN Committee on Economic, Social and Cultural Rights: Concluding observations on the sixth periodic report of the United Kingdom of Great Britain and Northern Ireland. 24 June 2016

I won’t repeat all of my earlier analysis of the cumulative impact of the cuts here. However I will note, as shown in Figure 13, that one of the features of the welfare state that enables such deception is its complexity.

Figure 13. The different cuts impacting disabled people

Complexity allows for various changes to go unnoticed or to be misunderstood:

  • Changes that happen over time, such as the failure to update benefits, take place slowly, but have a very large impact over time
  • Changes in assessment and eligibility can move people out of entitlement, and for new people they will not know they have lost out
  • Technical changes or rationalisations can be presented as modernisations or improvements in targeting, even if they are primarily cuts

The general rule of thumb in understanding political changes to the welfare state is not to look for fairness or rationality, but to try and identify where short-term political advantage lies. If the primary strategy is to provide tax-cuts to groups who will provide political support then making cuts at any point and by any means can be expected.

10. Poverty is a significant and growing problem in the UK

Poverty is not just political, it is also economic. The real situation is something as follows:

  • public and private wage inequality has increased significantly
  • the tax-benefit system has increasingly been used to lift the income of middle-income earners
  • taxes target the poorest and benefits have not risen accordingly

Over time inequality has increased as:

  • salary differentials have got worse
  • taxes have got more unfair
  • benefits have got worse for the poorest
  • but the system has got more generous in the middle

On a technical level I think this is also why the Gini Coefficient is a rather inadequate measure of inequality, because it gives too much weight to middle incomes. It makes much more sense to examine the discrepancy between the richest and the poorest, as Figure 14 does.

Figure 14. How inequality doubled in the UK

It is also important to ensure that in presenting data about poverty we do not fall into the trap of ignoring taxes. It is the post-tax and post-benefit data that is most important. So today, as Figure 14 shows, the UK has a very high level of inequality and a very high level of poverty. 6.5 million people must live on £51 per week after tax, to pay for all costs. This amount is totally inadequate and it is clear that even a modest tax increase for those on higher incomes could be used to radically increase the lowest incomes.

Figure 15. Inequality in 2016

This is why there are now 2,000 food banks in the UK. It is why mortality rates are falling for the first time since the creation of the UK. Poverty in the UK is severe, harmful and unjust – and completely unnecessary.

Redistribution and public services

So far I have restricted myself to three main factors in shaping poverty and inequality: income, tax and benefits. But there are other important factors, which are also subject to political influence, that also impact on poverty in the UK.

Positively the existence of free public services, like health and education, is a great leveller, although in practice there often great distortions in the distribution and quality of those services. Nevertheless universality that takes public services out of the money economy is generally very positive. The fact that social care remains highly means-tested is significantly regressive. The rich look after themselves and make no commitment to the public system, the poor often have to impoverish themselves further to ensure they are entitled to vital services.

It should also be noted that public services also create jobs, often very well paid jobs, for those with middle-incomes. This is worth considering when we examine the overall redistribution created by the welfare state. The poorest certainly benefit from public services, but society becomes more unequal when pubic services also increase wage differentials. In other words many middle-income earners have their income lifted twice, both through the tax-benefit system and by taking up work in public services. It is the poorest who lose out on both accounts.

This is not a criticism of public sector workers – far from it – it is just drawing attention to the strange way we think about income and public spending. If the Government increases the salary of a doctor this will be good for the doctor, but it makes no obvious difference to the service I receive and, from the perspective of equality, it is has made a bad problem worse.

Cost, debt and other complexities

The data that I have focused on here – incomes, tax and benefits – doesn’t tell us about some other very important facts:

  • Personal debt, which is a cost that has to be served and which is pushed up as incomes drop, is expensive for the poor, but cheap for the rich.
  • Housing costs, which have risen as the social housing has been suppressed and mortgages cheapened, become a bigger burden for the poorest whilst for the homeowner or landlord the costs go down.
  • Growing energy bills, increased through privatisation, hit the poor harder than the rich, because we all need to heat our homes (although now some can’t).
  • Lack of savings, growing job insecurity, lack of community resources, services or support and many other factors worsen the living situation of the poorest disproportionately.

Real poverty

There is no excuse, as some in the Government plan, for reducing our focus on the economics of poverty. However we should take a holistic approach and ensure that we also look at the costs people have to pay. Moreover we should also examine the social conditions which make it even harder to bear the costs of poverty. real poverty might best be pictured as having several dimension, as set out in Figure 15.

Figure 16. Real poverty

Personally I think we should move towards a more objective understanding of poverty, one which would enable us to eradicate poverty. I would define poverty as follows:

Poverty is the lack of all the resources necessary to participate as an equality in the life of the community

There is absolutely no reason why, by this definition, we cannot eradicate poverty from the UK.

Why does the system not care?

If we assume that politicians are not naturally unjust, but are primarily motivated by the desire to get re-elected, then there are a number of factors that may help explain recent developments.

In a two-party system, focused primarily on economic well-being, lifting the income of median-income voters is going to be critical. In addition you must disguise fact that you are doing so is also important (a) because you are failing to address the needs of people in the greatest need (b) benefits are stigmatised and those groups don’t want to be confused with stigmatised groups. Hence systems like tax credits are used to provide a benefit with lower levels of stigma for middle earners.

Furthermore this explains the increasing use of stigma, sanction, conditionality and control for those in the lowest income groups. Increasing the negative stigma associated with those on the lowest income also increases both a sense of superiority and a sense of insecurity – I don’t want to become like ‘them’. Abusing the poor becomes part of the street magic as it distracts people from noticing that most government policy is about subsidising the middle.

It is also important to acknowledge the changing structure of our society. If the interests of those who are poorest are unlikely to be represented, if people themselves are unlikely to organise to protect their interests, then exploitation is inevitable. Some of the more obvious social changes include:

  • declining trade union membership
  • declining church attendance
  • increased social atomism
  • declining social fabric in many communities
  • reduced level of political engagement

Poverty has been privatised. Without the necessary level of social solidarity and connectedness this situation is unlikely to change.

What next?

Although the current trend looks very negative I think there are some opportunities for positive change. The decline for middle-income earners which has helped erode our focus on poverty and inequality will increase. Technology and other economic changes is going to see more people, younger people, people in white collar jobs feel that the current system is unsustainable. You can only rob the poor for so long – they’re too poor for the trick to last for ever.

I think many more people are going to be attracted to the concept of basic income as a solution which universalises income security. In a sense the interests of the middle and the poorest will – if this happens – start to coincide. This should be a good thing.

I also think that a growing number of us will realise that an economic model which assumes that the only valuable activities are measured by money will collapse. The attractions of family, love, citizenship and community do remain, even in a world impoverished by injustice and shallow thinking. As people begin to reconsider what is of real importance then we can also start to consider how best to build a world where everyone’s gifts matter.

Meritocracy and neoliberalism will remain a threat to moral sanity. Things will not get better on their own. But we can unite around different values and use the emerging economic crisis as the basis for building something better.

This was first published by the Centre for Welfare Reform.

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The UK has one of the highest levels of income inequality in the developed world, and evidence shows that this harms our physical and mental health, hinders our education, damages our economy, restricts social mobility, reduces levels of trust and civic participation, and weakens the social ties that bind us.

We have astronomical pay inequality, with workers trapped on poverty wages while chief executives take home jackpot-like pay packets. Britain’s top bosses are paid on average 165 times more than a nurse; 140 times more than a teacher; 132 times more than a police officer, and 312 times more than a care worker. We have staggering wealth inequality, with the richest 1,000 people in Britain owning more wealth than the poorest 40% of the population put together.

We have a housing crisis which locks the vast majority of renters out of home ownership, with too many trapped in substandard housing, and an outdated council tax system that hits the poorest hardest.

We have a shocking gap in healthy life expectancy which condemns the poorest to 20 fewer years of healthy life than the richest.

We have unacceptable attainment gaps between equally bright children from richer and poorer backgrounds. We have people falling through gaping holes in our safety net, a record high for food bank usage, rising death rates for babies and the frail elderly, and rising child poverty.


Equality Trust

But it doesn’t have to be this way. Inequality is not inevitable. Here, The Equality Trust sets out its policy priorities for all political parties.

To effectively tackle the social and economic inequality blighting our society and to achieve a fair Brexit, we need fair work, fair tax, fair chances and a fair deal.

Fair Work

  • Protect and progress workers’ rights: strengthen trade union rights, introduce employment rights from day one, and ban forced zero-hours contracts.
  • Recognise the contribution of every worker: require large and mediumsized companies to publish the ratio of remuneration between the highest paid and the median employee, along with a justification of the ratio, annual changes to it, and a plan for its reduction.
  • Give workers a voice: require one third of the members of companies’ executive boards to be comprised of employees, and require elected employee representatives on remuneration committees.
  • Give workers a genuine stake in their workplaces: promote industrial democracy in our economy by encouraging the growth of the cooperative and mutuals sector.

Fair Tax

  • Ensure the broadest shoulders bear the greatest burden: reinstate the 50p top rate of income tax, which affects approximately the top 1% of earners.
  • Transform council tax into a progressive property tax: re-evaluate properties and create new bands with higher rates for high value properties.
  • Explore the most effective ways of distributing wealth fairly and efficiently: establish an independent Commission on Wealth.
  • Ensure business benefits our society: strengthen measures to tackle tax avoidance, reverse the race to the bottom on corporation tax and prevent the UK from becoming a tax haven.

Fair Chances

  • Help level the playing field and ensure pupils’ diverse needs are met: end selective education, properly fund a comprehensive education system for all, and introduce universal free school meals.
  • End child poverty: reinstate child poverty targets and commit to eliminating child poverty.
  • Reduce health inequalities and improve health for all: properly fund the NHS and social care, and address the root causes of poor health and the health gap.
  • End the two-tier justice system: abolish employment tribunal fees and restore legal aid.

Fair Deal

  • Tackle our housing crisis: establish a large scale house building programme, prioritising social housing and truly affordable housing, built to high quality and environmentally friendly standards.
  • Ensure Local Housing Allowance rates rise in line with increases in local private rents.
  • Let low-income families keep more of the money they earn: restore Universal Credit work allowances and reduce the taper rate to 55%.
  • Ensure everyone can keep up with rising living costs: restore the link between annual increases in social security levels and inflation.
  • Ensure public bodies consider how their decisions affect inequality: commence the socio-economic duty in Section 1 of the Equality Act 2010.

Will your local candidates tackle inequality?

Here are some suggested questions that we could all raise at hustings and other local and national events in the run up to the General Election to determine candidates’ commitment to a fairer society:

  • Would you support further tax cuts for billionaires over properly funding the NHS?
  • What would you do about the fact that nurses who care for our loved ones are paid hundreds of times less than bosses at some of our country’s biggest companies?
  • Do you believe children should be segregated at age 11 by a grammar school system that benefits the rich and hurts the poor?

Will you support us? The Equality Trust is working to reduce social and economic inequality in order to build a better society. But to do so we need your help. Our work depends on generous donations from individuals who share our vision. Please help support active campaigning for a fairer society by becoming a supporter of The Equality Trust.

  • Please visit to set up a Direct Debit; or
  • Please send a cheque payable to The Equality Trust to: Freepost EQUALITY TRUST; or
  • Please text EQUA16 £10 to 70070 to donate £10 (the JustGiving service accepts text donations of £1, £2, £3, £4, £5 and £10). We also welcome applications to affiliate to The Equality Trust from business, trade unions and the public sector, as well as from co-ops, charities, social enterprises and campaign groups.  And if you want to get involved in tackling inequality where you live, you can join or start a local equality group.

The manifesto was collective endeavor by the  Equality Trust, as everyone chipped in.   Lucy wrote it up and designed it.

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 – to improve public health the government must tackle inequality. Health policy must include a focus on social determinants

In one of the Government’s most short-sighted moves on the nation’s health, cuts to public health funding of more than £530m during this Parliament have been identified by the House of Lords select committee on the long-term sustainability of the NHS.

These cuts are being made at a time when the NHS is under mounting pressure to meet rising demand with dwindling resources and staff shortages exacerbated by Brexit. Public health funding should be a priority since it tackles the root causes of poor health that feed into demand.

Such cuts are further signs that this Government, as with many in the past, view the NHS as an ‘illness service’ instead of a means of supporting better health in a wider social context. Good health is seen as the personal responsibility of individuals rather than the result of a range of social determinants, which impact on communities and drive health inequalities.

Social determinants are as important as lifestyle or genetics in shaping life expectancy, morbidity rates and life chances. Life expectancy is shorter and disease is more common further down the social ladder.

Economic disadvantage, social exclusion, unemployment, the absence of social support networks, food insecurity, and poor housing are major determinants of our health status. Pollution from cars in city centres is a growing concern. And being a woman, from an ethnic minority and/or disabled are also key markers.

It is no fluke that the colloquial term for being ill is ‘poorly’. Being poor kills. It shortens and blights lives. The difference in life expectancy between inner city neighbourhoods and leafy, affluent suburbs can be as much as ten years.

The costs of poor health flowing from the impact of social determinants are startling. Take housing — it is estimated that a lack of housing at all (homelessness and rough sleeping), or inadequate, overcrowded or fuel poor housing, costs the NHS around £2.5bn annually. And housing is just one social determinant.

So, not is it only short-sighted of the Government to reduce public health budgets, the whole thrust of austerity policy over the last seven years has had major detrimental effects on our health.

The escalation in insecure work, the growth of poverty (especially among children), the proliferation of food banks, cuts in welfare support to low income groups and disabled people, and local government service retrenchment are all factors in the UK’s widening health inequality gap.

These social determinants of our national health may be feeding through into the first drop in life expectancy for decades.  Excess winter deaths of elderly people topped 40,000 last year, the highest number for 15 years. Growing inequality over the last for decades has also taken its toll the nation’s physical health and wellbeing.

The conclusion to be drawn here is that, even with extra funding for the NHS, the UK’s health crisis cannot be resolved without reversing cuts in expenditure on welfare and vital local services, seeking to create more secure jobs, delivering more affordable housing, and confronting levels of inequality that exacerbate poor health.

First published by Left Foot Forward

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Exact figures may be disputed but there is little doubt that social inequality and poverty are growing in the UK. Around four million people suffer from food insecurity, which means being hungry at least some of the time. There are even reports of people being hospitalised for malnutrition and claims of several deaths from starvation.

As an anthropologist who has worked for several decades on issues of food and food security in both Tanzania and India, I was shocked to discover in 2014 that a significant proportion of the UK population was currently experiencing similar problems to those encountered in much less developed economies. How could this be possible in one of the richest countries in the planet?

I started to investigate by studying food poverty and forms of food aid at the micro-level in two areas of the UK, one in the north London borough of Barnet and the other in a more rural part of west Wales. Much of my research has taken place in food banks and included interviews with both clients and volunteers, and serving occasionally as a volunteer myself.

Food poverty needs to be understood in its social context in order for long-term solutions to be found. It is this kind of fine-grained ethnography which enables connections to be made between the state and its policies, the market, and the voluntary sector.

While wages have risen very little if at all in most sectors and benefit entitlements have often been cut, some people turn to food banks as a coping mechanism. In the UK today, the main food bank charity, the Trussell Trust, has more than 400 such centres and there are likely to be at least as many independent food banks. They rely on long-life food donated by the public in supermarket and school collections.

Food poverty

The usual reasons for coming to a food bank include problems with benefits (including sanctions which means no benefits at all for a period of weeks), low-income and debt. Some clients have chronic problems, like this man:

I used to live in a middle class area of London and cared for my father. But when he died I lost both the flat, which was rented, and my job both at the same time. So I lived in my car for 3 years. Then I got another job, but it didn’t last because I had back problems… I am on pension credit which is paid every two weeks and I don’t have to pay council tax but it’s not enough to live on and pay energy bills, loan from bank, TV licence etc. I come here every Monday and it’s ‘thank goodness for the food bank’.

Others encounter a sudden emergency with which they cannot cope financially:

I used to work in administration, specialising in human resources. My problems developed after my husband deserted me and our 3 kids, as a result of which I had a mental breakdown and couldn’t work. So I went on to benefits but these were stopped because I had ticked the wrong box on the form. I have been to the food bank a couple of times and found the people there very friendly. I also had food given to me at Christmas by the food bank.

Food bank client in north London

Most food banks are run by volunteers, often out of churches, like this woman:

I heard about the food bank from my church, which had an item in the newsletter… People (clients) are here because of benefit cuts, sickness leading to loss of work, unemployment, disabilities, domestic violence, bills piling up. There are extremes of people who are so angry and bitter that it is difficult to talk to them, while others are so grateful they burst into tears and hug and kiss you. Often these people live alone, so they also come for company, they have a tea or coffee and feel slightly loved and cared for…

Volunteer at a north London food bank

Each food bank has a manager (volunteer or paid) one of whose responsibilities is to keep track of food, clients and volunteers:

Last year we gave out 1300 food parcels, of which roughly 300 might be to returnees (that is the national average). That means we fed 1000 people in a town with a population of 5,000. The main problems are benefits cuts and changes which account for maybe 60% of the people we see. When their circumstances change, benefits are cut until the new status comes into force. That might take several weeks and meanwhile people have nothing. Another is housing. I am expecting a client just now. She and her partner, plus their children, have just moved out of half-way accommodation. They are lucky – they only spent 8 weeks there before getting re-housed. But others spend many months in such places.

Welsh food bank manager

Alongside the problem of food poverty is one of food waste and surplus, which is generated by the food and restaurant industries, and by domestic consumers. While making use of the waste coming from restaurants is difficult, but not impossible, that generated by food retailers can be redistributed provided it is not past its ‘sell-by’ date.

A number of organisations, including well-established ones like FareShare and Foodcycle and more recent local additions, such as the Felix Project in London, collect food surplus from both wholesalers and retailers such as supermarkets. They use this to supply charities like homeless hostels, women’s refuges, and breakfast clubs which turn it into meals for their clients. Recently, FareShare has made use of an app to develop the FareShare FoodCloud, partnering initially with Tesco (and, more recently, Waitrose) to allow surplus food to be collected daily by different charities in a managed and monitored way.

It may thus appear that using the considerable surplus generated by the food industry and ensuring that is it channelled to organisations dealing with food poverty constitutes a win-win situation, effectively a problem solved.

In my forthcoming lecture in memory of the distinguished anthropologist Professor Mary Douglas, I shall be using some of her work and my own to argue against such a view. The late Professor Dame Mary Douglas was a prolific writer on many topics, one of which was food. Like other anthropologists, she was interested in the social and symbolic aspects of food and her work encompasses economics and social policy. Douglas maintained that giving out food was rarely the solution to more fundamental problems of poverty, a lesson which has been re-learned a number of times in contexts ranging from famine in Africa to food insecurity in the USA.

She argued rather that obtaining food should come from reciprocity either in the form of payment for labour or some other kind of reciprocal exchange. Where food is given out without any commensurate return, it is a form of charity which only alleviates an immediate problem, but not the reasons for its existence. Her argument draws upon classic anthropological work on gift-giving which demonstrates that gifts should not only be received (never look a gift horse…) but also returned.

It is for this reason that receiving something for nothing creates a highly asymmetrical status between giver and receiver, which is why many people feel that it is stigmatising to go to a food bank. While many clients feel gratitude for the help they receive, most also feel shame, because in accepting such help, they deem themselves to be failures. Such a view is reinforced by much of the media which views clients of food banks and other food aid organisations as ‘scroungers’.

Most food banks and other food aid organisations recognise that their solutions are imperfect and hope that the need for them will be temporary, but argue that people cannot be left to suffer hunger when it can be alleviated, so ‘in the meantime’, their efforts remain necessary.

In the 2017 Mary Douglas Memorial lecture, I consider where responsibility for food poverty lies and how more fundamental solutions to it may be found.

First published on the  British Politics and Policy blog

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Councils can make a huge contribution to tackling health inequalities across Scotland. The interaction and relationship with the Scottish Government is pivotal to making a difference.

National recommendations for action:

Funding: Reform the resource allocation to local authorities to ensure that it is based on socioeconomic circumstances of communities.

Income: Reform Council Tax and create fairer local taxation.

Structures: Further work to reform local authority structures -balance between local and regional services and integration with wider public services, particularly the NHS and public health services.

Local recommendations for action:

  1. Priorities: This is about priorities and decisions. Tackling health inequalities should be the top priority for councils. All other roles and actions of local government contribute to narrowing inequalities in health, wellbeing, and life expectancy inequalities in their populations.

  2. Education and Schools: Ensures schools develop social, emotional, health and wellbeing agendas as a foundation for learning. Schools can do more to promote physical activity and improve the nutritional value of school meals. Free school meals and the provision of breakfast has long been an important public health measure. Resolve the crisis in Additional Support Needs education.

  3. Physical Environment. How the environment can be improved including reducing air pollution, a major cause of death in Scotland. Councils and health boards also have a statutory duty to reduce carbon emissions as part of their climate change plans.

  4. Food policy. Further action to improve healthy food in schools and other local authority settings. Wider action to improve access, affordability of healthy food. In addition to the key environmental health role in better food safety.

  5. Active and Affordable Transport. An active transport plan not only reduces carbon emissions but also contributes to better health. Traffic management measures can reduce accidents that disproportionately impact on poorer areas.

  6. Early years provision: This requires universal provision delivered by qualified staff, not just child minding, and can be an important setting to deliver health improvement such as toothbrushing, hand hygiene, dietary habits, and also venue to engage parents and carers.

  7. Housing: Council should be building and refurbishing more social housing and supporting a fuel poverty strategy through energy efficiency standards and measures. A warm, dry house is an essential element on any health strategy.

  8. Licensing: Using planning and licensing powers to address number and distribution of alcohol, gambling, and unhealthy fast food outlets.

  9. Economic powers: Using economic powers support regeneration of disadvantaged communities and help people to find and stay in good quality jobs. Procurement powers should promote fair work practices, including the Scottish Living Wage.

  10. Voluntary groups: Supporting community groups that help develop strong resilient communities.

  11. Community development and participation: Invest in community development and build better systems to ensure genuine community participation in local policy development.

  12. Leisure and culture facilities: Maintaining and developing cultural and leisure facilities that promote good health, ensuring access for all. Improve affordability and access.

  13. Exemplar Employers: As employers, develop fair work practices with well designed and paid jobs. Promote healthy workplaces with first class occupational health services.

  14. Care services. Social care services should be developed focusing on improving care workers pay, training, working conditions, as well as improving standards and regulations. This also means supporting collective services like day care, which tackle social isolation, particularly for older population.

Life expectancy in Scotland

No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government.

Through their planning powers, management of transport and traffic systems, open public spaces, and leisure and cultural services, they can contribute to the quality of the built and social environment. They have powers to promote equality and wellbeing. They work in partnership with the NHS and other agencies such as the police, and voluntary & community organisations to support public health by leading community planning. In short, they make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age.

Rising demand on the NHS and a growing funding gap means that our current health and care system is creaking at the seams. Addressing this requires a shift from the treatment of ill-health to preventing it. Above all health inequalities remain Scotland’s most urgent health issue.

As our National Commission on Health Inequalitiesi highlighted, too often solutions are focused solely around the NHS. In practice many of the policy levers rest with local government and they are well placed to influence the wider determinants of health. Not least because of there close connection to communities and their role in coordinating how best to use all the available assets to promote well-being.

In this paper we make the case for health and well being to be central to the purpose of our councils – recognising that they have to be fairly funded to make meaningful interventions.

How councils contribute to a healthier Scotland

Services like refuse collection, street cleaning, dealing with fly-tipping, and environmental health directly ensure that we avoid ill health by removing the sources of disease from our communities. Living in pleasant surroundings rather than litter-strewn streets and accessing cultural facilities are also good for mental health. Sports centres, parks, and allotments offer free or inexpensive routes for people to keep fit, active and healthy no matter their age or ability. These are essential health services.

Local government also delivers direct health and care services: free personal care for the elderly, care homes support and adaption’s for people living with disabilities and chronic health conditions. These services save lives and are essential to the quality of life of many Scots. Without those lots of people would still be in hospitals, unhappy and costing a great deal more money. Housing is also a key health service. A decent safe secure affordable home is vital to both mental and physical health.

Education and the tackling the educational attainment gap is essential to addressing health inequalities. As well as teaching the subjects children need to pass exams and get jobs, schools deliver a range of health and relationships education. Schools are important settings for implementing healthy food and physical activity policies. Schools are also the gateway to a range of other agencies that can support families like educational psychologists and social workers. Ensuring that children have the best possible start and make good choices about their own lives and health will not only mean they have better lives but that we can look forward to long term savings. What the Christie Commissionii called preventative spending. The Childsmile – national supervised toothbrusing programme in nurseries is a case study in preventative spendiii. There is also a crisis in the inclusion and support for Additional Support Needs children in Scottish schools with a postcode lottery in how this is delivered.

The role of the councillor is recognised by NHS Health Scotland in their elected member guidanceiv. They describe the role of the councillor “as very important in terms of influencing the positive health of communities and ensuring the gap between our more affluent communities and individuals and those not so well off, isn’t widened.. Councillors are the key advocates for their communities and for ensuring tackling health inequalities is central to the purpose and work of the local authority.

Some councillors also have a direct responsibility for the delivery of health services. Every council is represented on their health board, providing the only local democratic accountability health boards have since the decision to abandon direct elections. Others serve on Integrated Joint Boards tasked with coordinating the provision of community health services and social care. Councils also lead community-planning partnerships.

Councils also invest in community development to build local capacity to respond to local needs. Single Outcome Agreements should include clear outcome measures for reducing inequality and health inequalities, together with the commensurate resources targeted on greatest need. This should lead to the development of greater resilience enabling individuals and communities to withstand challenges such as poverty, inequality, worklessness and other factors that endanger health and wellbeing.

Lessons from elsewhere

The transfer of public health from the NHS to local government and Public Health England (PHE) has been viewed in England as a significant extension of local government powers. Public Health England has published a range of resourcesi that promote good practice. Their focus is on good quality jobs, reducing social isolation and improving health literacy. While Scottish local government doesn’t have the same explicit powers, it shows the advantages of better links between public health practitioners and local authority teams. A number of local guidesii emphasise the role of councillors in health.

In London, there is a collective agreementiii with national partners to transform health and wellbeing outcomes, inequalities and services, through new ways of working together and with the public. The Marmot Review also includes examplesiv of how local action can tackle health inequalities.

Across Europe, local government and health work together more closely. In some cases unitary authoritie join up community health and other services. Norway, a country of similar size to Scotland does this. Although they would say that the division between acute and community services is just as challenging.

While the centralising tendencies of the Scottish Government means similar structural change is unlikely in Scotland, we can learn the lessons from elsewhere, use relevant resources and adopt best practice that can support local action. The Scottish government has set a direction for public health in Scotland.

Council Health Strategy

The starting point should be a political strategy for the council to engage with a health equality agenda. This strategy shows how the council can make positive interventions, sometimes described as ‘place-shaping’. Sir Michael Lyons in his influential report, ‘Place-shaping: a shared ambition for the future of local government’, described ‘place shaping’ as the creative use of powers and influence to promote the general well-being of a community and its citizens. He said that local authorities must use their ability to bring together local stakeholders and develop a vision for their area.

This should be developed in conjunction with community, voluntary groups and trade unions. Councils are the democratically elected representatives of their communities and should use that role positively to improve engagement in health issues. All policies should be measured against their contribution towards reducing health inequalities and resource allocation should be focused on disadvantaged areas.

The strategy should include a health profile that gives councils information about the health of there own residents. This should include data available about health inequalities between different groups, such as men and women, older and younger people, people from different ethnic groups, which enables councils to make interventions targeted at improving the health of groups most in need.

Councils are represented on health boards and Integrated Joint Boards, but rarely take a strategic approach to their role on these bodies. They should take their health agenda forward using these roles.

In a practical sense, councils can help health boards by refinancing health PPP schemes as set out in UNISON Scotland’s Combating Austerity toolkit. The money saved should be invested in tackling health inequalities that address the council’s health strategy.

Co-locating health and local government services is a good way of delivering seamless services, designed by staff and service users from the bottom up. Community hubs as described in the Health Inequalities Commission report and the Reid Foundation paperi, show how this can be done.


Local government can make a huge contribution towards a healthier Scotland. Both directly through the services they deliver and in partnership with the NHS and others. They can bring the authority of local democratic accountability to a wide range of services.

When we focus on the social determinants of health, rather than the medical cause of some specific disease, we see that local government services are health services. Without local government, adults and children would die sooner, would live in worse conditions, would lead lives that made them ill more often and would experience less emotional, mental and physical well-being than they do now.

However, strengthening the role of local government won’t happen by accident. Councils need to adopt health strategies that focus relentlessly on tackling health inequalities. And the Scottish government must stop slashing council budgets to enable councils, and better distribute resources based on socioeconomic deprivation to enable them to deliver their full potential to tackling inequalities in health and wellbeing. Health inequalities will not be eliminated unless we seriously address the social determinants of health – that is where local government must play a key role.

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In December 2015 I was approached by Jeremy Corbyn and Kate Green, then the shadow minister for women and equalities, to chair a review with an advisory group made up of academics, policy experts, elected representatives and grass roots organisations to make recommendation on a future race equality strategy. On the eve of the anniversary of the 1965 race Relation Act, Jeremy Corbyn stated: “Fifty years ago today (December 8) the Labour government of Harold Wilson introduced the first Race Relations Act – outlawing discrimination based on ethnicity. Labour has a strong track record. As recently as 2010 we passed the Equality Act.”

Two events in December 2015 and February 2016 started the 18 month process of collecting evidence and having dialogue with a range of stakeholders inside and outside the party.  The race equality advisory group was established in February 2016 to lead a consultation and make recommendations to Jeremy and the shadow team on key issues for Labour to consideration around policy development. In addition, as part of the review of the party’s governance structures, Shabana Mahmood and Kate Osamor were also conducting a review around BAME representation for the national executive committee.

However, the shadow cabinet resignations and the leadership race had a major impact on the review. Also the party focus was around the issue of anti-Semitism, which led to the Shami Chakrabarti report. The timescale for the review has been scaled down further especially if there is an early election as a result of the fallout of Brexit.

There is now a greater degree of urgency to respond to this consultation. The feedback will help shape Diverse Communities Manifesto which is being led by Dawn Butler, shadow minster for diverse communities. We are looking for written submissions by January with plans to prepare a report early in the new year.

The timing of this review is important as race is now slowly back on the political agenda as a result of the reports in August 2016 by UN Committee on race (CERD) which, every five years, reviews Britain’s record on race equality. There has also been a rise in hate crime since Brexit, rather depressingly.  In response to these reports Theresa May is now conducting a government wide public audit on race equality. Elsewhere David Lammy is continuing his review of the criminal justice system and impact of BAME communities.

It is clear that structural racism and social mobility are major issues in Britain which the coalition and the Conservative government not only failed to address but, in many ways, exacerbated with an austerity programme and failure to implement the Equality Act 2010. Too often the government and the media have spent excessive time debating migration of Eastern Europeans from the EU and the experiences of refugees caught in war and conflict. By doing this, we miss the real debate about the increasing wealth, income and power of exclusivity and privilege  taking us back to Victorian Britain. Today working class, women, disabled, LGBTI and BAME communities are further disfranchised and marginalised economically and socially.

As a result of the EU referendum there has been a fivefold increase in hate crime and uncertainty for millions of people from migrant and BAME backgrounds about their future status in this country. Global campaigns and the domestic launch of Black Lives Matter highlight racism faced by Black British people who are racially profiled and on occasion have died in police custody or a secure environment. The Prevent strategy, which aimed to tackle fundamentalism with the Muslim community, actually increased Islamophobia. We have now reached a crossroads in Britain where there is growing racial, social and class divide. We must call in to question how tolerant are we society in 2016.

Despite individual BAME achievement and success in politics, medicine, science, public services, media, sports, the arts and business, these communities still face discrimination. It has led to a growing gap between survival and aspiration which risks holding back third and fourth generation young BAME people despite their qualifications and abilities.

In many ways it feels we are going backwards as a society to the time just after the second world war with the arrival of the SS Windrush ship in June 1948 where the colour bar and infamous slogan used many landlords, and indirectly by employers, was “No blacks, No Irish and No dogs”. It was a fact of life regardless of the fact many of the migrants from former colonies now part of the Commonwealth served in the war and their parents made a similar contribution between 1914 and 1918.

Sixty years on and, despite race equality legislation which successive Labour government introduced, structural and interpersonal racism is getting worse, much like inequality. The Olympics in London was one of the most successful games built around the vision of diversity and inclusion but it feels like a dream and illusion after the toxic campaign during the EU referendum.

That is why Angela Rayner, shadow education secretary and shadow minister for women and equalities, and I launched a race equality consultation in August 2016 around the time of the EHRC and United Nations CERD.

Jeremy Corbyn also has recently reaffirmed his commitment in placing race equality as part of his future vision for Britain at a recent Black History Month reception.

We are still seeking the following responses to the key questions below as part of the consultation:

  • What would you identify as the key issues and themes around race equality that need to be addressed over the next five to ten years?
  • What are the top three policy measures/actions you would like to see to promote race equality?
  • What is the best way to ensure race equality is given full consideration in the policy and manifesto development process of the Labour Party?
  • What action should be taken to help eliminate race discrimination in Britain?
  • What action should be taken to protect race equality legislation now that the UK has decided to leave the European Union?

See the consultation document here and submit your response to by 13 January 2017.

Finally, although we have the best race equality legalisation and practice in Europe, there is still a lot of work to done to tackle structural issues affecting BAME communities in relation to health and social care, housing, education, stop and search, business, employment, the arts, and civic and public life.

It important to acknowledge the achievements and aspirations of our multicultural and faith society in working towards a fair and just Britain for all – that is why Brexit negotiations and parliament must accept this.

First published by LabourList

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This is a slightly edited version of Chapter 6, the discussion of health inequalities policy, from the book Health Divides. The printed version is fully referenced.

Previous chapters have explored the relationship between health and place across different scales showing consistent evidence of spatial inequalities in health within local areas, between the regions and countries of the UK, as well as within and between countries internationally. They have shown that the causes of geographical inequalities in health are complicated and multifaceted, a combination of compositional (people), contextual (environment) and ultimately political and economic factors. This chapter examines how public policy has had an impact on health divides using a case study of the UK since the 1980s. It provides an overview of health inequalities policy since 1979, drawing on the key actions during this period. The successes and failures of UK policies in terms of reducing health inequalities are critically examined with reference to the wider context of the neoliberal political economy and the social and spatial determinants of health.

The UK is chosen as a case study because the Thatcher governments of 1979—90 played an important role in the promotion of the international neoliberal policy agenda, which remains influential today; because the Blair Labour governments from 1997 to 2010 implemented the most extensive health inequalities strategy in Europe; and because the coalition and Conservative governments since 2010 implemented austerity. The chapter critically reflects on how policy has had an impact on health inequalities from 1980 to 2015, analysing some of the key developments in this period. It ends by reflecting on what could or should have been done, drawing on evidence from a series of government-commissioned reviews into tackling health inequalities.

Thatcherism and health inequalities, 1979-97

The need to reduce health inequalities across the UK contributed to the decision to establish the National Health Service  in 1948. Yet, despite this universal, free at the point of use health service, by the 1970s it was becoming increasingly evident that free access to healthcare had not been enough to stem socioeconomic and spatial inequalities in health. In as far as a health inequalities policy existed at this time, it was within the NHS. So, in 1977, the Labour government (1974-79) faced fresh calls to do something about the issue. They responded by asking the Chief Scientist, Sir Douglas Black, to appoint a working group of experts to investigate the issue and to make policy recommendations for the government. The resulting report, which is widely referred to as the Black Report, argued that materialist explanations were likely to play the largest role in explaining health inequalities, and, therefore, that policy-makers ought to prioritise the reduction of differences in material and economic circumstances between socioeconomic groups and between deprived and affluent areas. The report was published in 1980 (on a Bank Holiday Monday in August to minimise publicity, and with only 260 copies produced), when the commissioning Labour government (left-wing, social democratic) had been replaced by the first Thatcher-led Conservative (right-wing, neoliberal) government (1979-83). The new government wholeheartedly rejected the report’s recommendations (which included increasing welfare benefits and decreasing child poverty). In an infamous foreword to the report, Patrick Jenkin, the then Secretary of State for Social Services, claimed that the report was ‘wildly unrealistic’ and ‘seriously flawed’. This set the tone for the next 20 years as, under the Conservative governments of 1979—97, health inequalities were not on the official policy agenda at all. Even the term ‘health inequalities’ was discarded, and health differences between socioeconomic groups and places were instead referred to using the less emotive term, ‘health variations’, implying that health differences could be ‘natural’, individual and therefore not something for which politicians and policy-makers were responsible.

Table 6.1: Overview of the Black, Acheson and Marmot reports

Black Report Acheson Report Marmot Review
The Black Report (1980) on health inequalities was commissioned by the outgoing Labour government in 1977 and brought health inequalities into the spotlight and represented the first example of a comprehensive strategy to draw attention to health inequalities over the life course. Health inequalities were not recognised as a problem by many at the time. The Independent Inquiry into inequalities in Health chaired by Sir Donald Acheson was commissioned by the newly-elected Labour government in 1997, which committed itself to implementing the evidence-based policy recommendations. Following publication of the WHO report on the social determinants of health, Sir Michael Marmot was commissioned to consider the implications for health inequalities in England post-2010. As with the Acheson Inquiry, the Marmot Review was expected to make evidence-based recommendations.


1. To assemble available information about the differences in health status among the social classes and about factors which might contribute to these, including relevant data from other industrial countries; 1. To review the latest available information on inequalities of health, to summarise the evidence of inequalities of health and expectation of life in England and identify trends. 1. Identify, for the health inequalities challenge facing England, the evidence most relevant to underpinning future policy and action
2. To analyse this material in order to identify possible causal relationships, to examine the hypotheses that have been formulated and the testing of them, and to assess the implications for policy; 2. In the light of that evidence, to conduct – within the broad framework of the Government’s overall financial strategy – an independent review to identify priority areas for future policy development, which scientific and expert evidence indicates are likely to offer opportunities for Government to develop beneficial, cost effective and affordable interventions to reduce health inequalities. 2. Show how this evidence could be translated into practice
3. To suggest what further research should be initiated. 3. To report to the Secretary of State for Health. The report will be published and its conclusions, based on evidence, will contribute to the development of a new strategy for health. 3. Advise on possible objectives and measures, building on the experience of the current PSA target on infant mortality and life expectancy
 4. Publish a report of the Review’s work that will contribute to the development of a post-2010 health inequalities strategy.

 Explanatory theory

Took a multi-causal approach to explaining health inequalities but suggested the role of behavioural and cultural determinants in producing inequalities in health were significantly outweighed by the role played by economic and social conditions. Acheson also supported a multi-causal approach to explaining health inequalities, using a model composed of different layers including individual lifestyles and the socioeconomic environment. Similarly to Black, this approach emphasised the importance of material and structural conditions in shaping other key determinants, such as lifestyle-behaviours. The distribution of health and wellbeing is once again understood to be caused by interplay of various determinants, with material circumstances playing an important role. However, psychosocial factors such as social cohesion, and other social stresses are given more prominence in explaining the relationship between material inequalities and health inequalities.

 Key Recommendations

37 recommendations, prioritizing giving children a better start in life within a wider anti-poverty strategy 39 recommendations; key priorities similar to those of Black report, namely; 6 policy objectives:
1 . All policies likely to have an impact on health should be evaluated in terms of the impact on health inequalities. 1. Give every child the best start in life
2. High priority should be given to health of families with children. 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives
3. Further steps should be taken to reduce income inequalities and improve living standards of poor households 3. Create fair employment and good work for all
4. Ensure healthy standard of living for all
5. Create and develop healthy and sustainable places and communities
6. Strengthen the role and impact of ill health prevention

See also Tackling Health Inequalities in the UK 1997-2010 – Evaluating the Acheson report

Understanding Thatcherism, Conservatism and New Right ideologies in this period helps explain why Thatcher’s government made the decision to reject the recommendations put forward in the Black Report (1980). Margaret Thatcher (1925-2013) was UK Prime Minister from 1979—90. Her critique of UK social democracy during the 1970s and her adoption of key neoliberal strategies, such as financial deregulation, trade liberalisation and the privatisation of public goods and services, were popularly labelled ‘Thatcherism’. Thatcherism was an ideological project that set out to radically re-cast the relationship between labour and capital and between the state, society and the individual. Thatcherism and the New Right provided a narrative that explained the crisis of British capitalism in the 1970s as a crisis of the welfare state, high wages and low productivity, of the ‘undemocratic’ power of what in 1984 she called ‘the enemy within’, that is, the trade unions. Thatcherism set out to systematically dismantle the structures of the post-war Keynesian consensus around the social wage, full employment, the corporatist state and the size and role of the public sector. This goal was pursued through the aggressive promotion of the free market alongside the ‘hollowing out’ of the state.

Thatcher’s political programme included:

(1) deregulation of the labour and financial markets (including the ‘big bang’ deregulation of the City of London in 1986);

(2) the privatisation and marketisation of the main utilities (water, gas and electricity) and state enterprises (for example, British Steel, British Rail and British Airways);

(3) the promotion of home ownership (including the widespread sale of public housing stock under the ‘Right to Buy’ scheme);

(4) the curtailing of workers’ and trade union rights (for example, bans on the ‘closed shop’, obligatory membership ballots before any industrial action, restrictions on the right to picket including a ban on secondary picketing, and removal of trade union immunity from damages);

(5) the promotion of free market ideology in all areas of public life (including healthcare and the civil service);

(6) significant cuts to the social wage via welfare state retrenchment (for example, a 7% reduction in state expenditure on social assistance between 1979 and 1989; removal of 16- to 18-year-olds from entitlement; reductions in state pensions; abolition of the inflation link for welfare benefits);

(7) an acceptance of mass unemployment as a price worth paying for the above policies; and (8) large tax cuts for the business sector and the most affluent (for example, during Thatcher’s premiership, the rate of Income Tax for the top tax bracket was reduced from 83% to 40%).

These changes all led to a fundamental rebalancing of British economic and social life that saw a reassertion of social class divisions. The growing economic equality experienced as a result of UK social reforms since 1945 was reversed, with income inequality increasing significantly (for example, the richest 0.01% had 28 times the mean national average income in 1978, but this increased under Thatcher’s tenure to 70 times in 1990). Additionally, as a result of welfare state retrenchment, high unemployment and falling wages for many poorer workers (due to the decreased bargaining power of trade unions), there was a near doubling of poverty rates in the UK, from 6.7% in 1975 to 12.0% in 1985 By the 1990s and 2000s, these new high levels of income inequalities and poverty became normalised. Social mobility gains were also stalled via changes to the education system as well as the ‘lost generation’ of young people who left school and went straight onto ‘the dole’ in the early 1980s. From 1980, the number of unemployment claimants rose from around 1 million to around 3 million in 1983, and a further peak was seen in the early 1990s. Meanwhile there was also a steady rise in the number of claimants of long-term sickness (disability) benefits. The rise in the number of disability benefit claimants has been attributed to a government desire to move people off the unemployment register and because of the lack of jobs in the economy.

The new economy that emerged in the 1980s was seriously unbalanced. Manufacturing and extraction industries, public utilities and collective housing provision were displaced by finance and banking industries, privatised utilities and rampant property speculation. The ‘big bang’ of 1986 saw the deregulation of the City of London, and with that, the unleashing of hitherto unimaginable forms of financial speculation. The ostensible ‘giving power back to the people’ through privatisation led, in fact, to the radical de-democratisation of the power industry — now largely externally owned — and other utilities. And the ambition to create ‘a nation of homeowners’ produced a mushrooming of homelessness due to a chronic shortage of affordable social housing, creating the preconditions for the more recent emergence of a new breed of ‘Buy to Let’ landlords charging ‘market rents’. It also underpinned a new culture of speculation and chronic indebtedness – on which a new breed of amoral ‘entrepreneurs’ in banking and finance would be able to prey. All of this generated sharply increased inequalities of income and wealth across Britain, and a dramatic increase in poverty. It also put in place most of the prerequisites for the great banking and finance crisis of 2008. In this way Thatcher’s governments wilfully engineered an economic catastrophe across large parts of Britain, and began the dismantling of the welfare state and the privatisation of the NHS in England.

The impact of these changes on other key social determinants of health was, in many cases, dramatic. Inequalities in educational outcomes and in access to healthcare, for example, both increased following policies implemented under Thatcher’s leadership. In housing, Thatcher’s government quickly implemented a ‘Right to Buy’ initiative, which gave council tenants the right to purchase the homes they occupied, often at greatly discounted rates. This policy reflected the ideological belief in the superiority of the market and was popular among many of those it helped move into the housing market. However, it contributed to the growing wealth inequalities and, more broadly, the policies of Thatcherism sowed the seeds of the housing market crash in 1989, which left many homeowners trapped by ‘negative equity’. Meanwhile, as the better quality houses were sold off, local councils were left with responsibility for a far smaller and increasingly poor quality housing stock. All of this contributed to growing levels of homelessness. Longer term, these significant changes in housing policy also resulted in the current housing crisis in the UK.

Although Thatcher backed off from any wholesale reform of the NHS, allegedly fearful of an adverse public reaction to such a move, her government did introduce a number of policy initiatives that set the NHS on a course from which it has not deviated since. That course might be characterised as a shift from a welfare state to a market state. The most significant NHS development that took place under her premiership was the introduction of a quasi-market in healthcare centred round competition and choice. Among the most controversial changes Thatcher introduced was the policy of contracting out or outsourcing, introduced in 1983, whereby health authorities were required to set up competitive tendering arrangements for their cleaning, catering and laundry services. Additional non-clinical services were later added to the list. The main significance of this development was the establishment of the principle that the core responsibility of health authorities was no longer to directly provide non-clinical services, but merely to ensure that they were in place at the least cost. A key negative impact was a loss to the public sector ethos of the NHS in which, for example, cleaners were perceived as members of the ward team, whose friendly, reassuring presence made important contributions to the wellbeing of patients. This contribution disappeared once the tight schedules of competitive contract cleaning took over. Equally important was the perception that ward cleaning became substantially less thorough, leading over time to the current high prevalence of hospital-acquired infections. The NHS and Community Care Act 1990 introduced market-style mechanisms into the NHS, notably the purchaser—provider separation and GP fundholding, whereby GPs were allocated budgets that they were free to spend as they saw fit, to meet their patients’ needs. This marked a substantial break with the past, and opened up the NHS to market forces.

These significant and rapid social and economic changes had an impact on health divides in the UK. Mortality rates in the UK, and across Western and Central Europe, have been improving for around 150 years. This long-run improvement continued throughout the period of the Thatcher government, with all-cause mortality rates declining at a similar rate to those in other countries and compared to the time periods before and after. However, underlying the overall improvement in mortality rates, some specific causes of mortality increased markedly, either during the period of the Thatcher government, or immediately afterwards. For example, alcohol-related mortality increased dramatically during the late 1980s and early 1990s in the UK in contrast to the improving trends in other parts of Europe.

Increases were also seen in drug-related mortality, suicide and violence at this time, all of which are causes of death that are clearly socially produced rather than due to biological or physiological mechanisms. Further, within the UK, mortality rates improved much more slowly in Northern and inner-city areas than in the more affluent Southern England, to the extent that in some local areas, mortality rates actually worsened. Indeed, for young adults in Scotland there has been no improvement over the course of the last 30 years. Figure 6.1 shows that the gap in mortality between the least and most deprived postcode areas in Scotland increased rapidly between 1981 and 2001, to leave Scotland with the highest inequalities in Western and Central Europe. The rise in spatial inequalities in health during the 1980s was also reflected in a rapid rise in mortality inequalities by occupational social class in England and Wales. Life expectancy increased for all social class groups among males and females over time, but the increase was more rapid among higher social classes than in lower ones, such that the inequalities increased (see Figure 6.1). The rises in cause-specific mortalities such as alcohol- and drug-related deaths, suicide and violence, and the widening health inequalities occurred during the same time period in which unemployment, poverty and income inequality all rose.

Trends in health inequalities

Figure 6.1: Trends in health inequalities in England and Wales, 1975-2003 (by occupational social class) and Scotland, 1981-2001 (by Carstairs area deprivation)

New Labour and health inequalities, 1997-2010

Labour was re-elected in 1997 with a landslide victory and a manifesto that had highlighted the need to tackle various social inequalities, promising to tackle the ‘root causes’ of ill health, such as poor housing and unemployment. The new government was keen to emphasise the previous Conservative government’s failure to address health inequalities. The Labour government initially criticised the Conservatives for placing an ‘excessive emphasis on lifestyle issues’, casting the responsibility for ill health onto individuals rather than the economic and social structures of society and the places where people live. In addition, and as promised in their manifesto, the Labour government commissioned a follow-up to the Black Report, announcing an independent inquiry into health inequalities.  The Acheson Inquiry, as it became known, was commissioned by Tessa Jowell, the first ever Public Health Minister. On publication in 1998, its recommendations were officially welcomed, used as the basis of a new health strategy, and the government stressed that they were already implementing many of them.

In broad terms, many of the resulting Acheson Report’s 39 recommendations reflected the conclusions of the earlier Black Report: both highlighted the need to have a multifaceted approach to health inequalities, and both advocated a reduction in income inequalities, with a particular focus on child poverty.

The key difference was that the Acheson Report was released in a far more favourable political climate than its predecessor and might, therefore, have been expected to have more of a policy impact. However, Labour had also stipulated that the Inquiry’s recommendations should recognise the government’s fiscal commitments which, at that time, included a two-year agreement not to increase public spending. This restriction led to an under-representation of any attempt to tackle the fundamental economic and political determinants in the emerging policy initiatives that were linked to the report.

A wealth of policy statements referring directly to the report were produced, indicating that policy decisions had, as promised, been directly informed – or at least influenced – by the recommendations of the report. Certainly in the period 1997-2003, health policy across the UK reflected some of the ideas set out in the Black and Acheson Reports, including a consistent rhetorical emphasis on the need to tackle the social and economic determinants of health inequalities as well as a commitment to employing cross-cutting government policies (that went beyond the Department of Health and the NHS) to tackle health inequality. Most notably, by 2004, national targets to reduce health inequalities were also introduced with a focus on life expectancy and Infant Mortality Rate.

These targets, however, reinforced the idea that policy-makers could tackle health inequalities through specialised health improvement measures, directing efforts to the least well-off individuals and areas such as the Spearhead local authorities that were the 70 most disadvantaged local authorities in England. They all received additional financial resources to improve area health, and area-based initiatives emerged. These tried to get different sectors – particularly the NHS, local authorities and the voluntary sector – to work in partnership together to improve the health outcomes of a specific deprived area. Examples from this period include Health Action Zones, Healthy Living Centres, Health Improvement Programmes and New Deal for Communities . This target culture is perhaps one reason why, in the period 2004-07, public health policy moved away from the initial concern with social and economic determinants and instead focused increasingly on health services and lifestyle behaviours. This shift was associated with a reduction in the level of responsibility that the central government appeared to be taking for health inequalities, as policy documents increasingly emphasised the importance of individual responsibility for health outcomes. Targets to reduce health inequalities were abandoned across the UK in 2011.

Description of area-based health initiatives, 1997-2010

Health Action Zones (HAZs)

HAZs were area-based initiatives designed to tackle social exclusion and inequalities. Acknowledging the wider determinants of health, HAZs were intended to develop partnership working between the NHS, local government and other sectors with the aim of tackling ill health and persistent inequalities in the most disadvantaged communities across the UK. Initially 11 HAZs were launched in the first wave in April 1998, followed by a further 15 in April 1999. Collectively, HAZs were awarded £320 million over a three-year period. It was originally intended that the lifespan of HAZs would last between five and seven years, with successful services being mainstreamed thereafter. However, HAZs were effectively wound down by 2003.The projects facilitated by HAZs varied extensively, but included initiatives that aimed to address social and economic determinants (such as services providing advice on benefit support); promote healthy lifestyles (for example, breakfast clubs); empower individuals and communities (for example, a Gypsy and Traveller Project Advisory Croup); and improve health and social care services (for example, the Integrated Substance Misuse Service).

Health Improvement Programmes (HImPs)

HlmPs were action plans developed by NHS and local government bodies working together. They were introduced in 1999 and, despite being re-named Health Improvement and Modernisation Plans in 2001, they continue to form a key approach to public health in England. The plans set out how these organisations (with, where deemed appropriate, voluntary and private sector input) intend to improve the health of local populations and reduce health inequalities. The programmes offered a three-year plan for identifying local health needs and developing relevant strategies to improve health and healthcare services at a local level. HlmPs were founded on the basis of multi-agency partnership working between local government and regional Strategic Health Authorities (SHAs).

New Deal for Communities (NDC)

As part of the Neighbourhood Renewal Strategy, NDC was developed to tackle health and social inequalities experienced by the 39 most deprived communities in the UK. In partnership with local communities, NDC sought to address embedded issues of deprivation and long-term poverty by improving outcomes in terms of housing, education, employment and health. Interventions mainly focused on promoting healthy lifestyles, enhancing service provision, developing the health workforce and working with young people.

Healthy Living Centres (HLCs)

HLCs were introduced in 1998 to tackle the broader determinants of health inequalities and to improve health and wellbeing at a local level. Funding was awarded for 352 community projects that varied in terms of focus, ranging from service-related issues to activities addressing unemployment, poverty and social exclusion. Example interventions included health-focused projects such as a physical activity outreach programme in rural localities, support programmes such as a Community Health Information Project that trained members of the local community to act as ambassadors for HLCs, and services such as ‘Bumps to Babies’, which provided midwifery and health visiting services for young families.

The effects on actually reducing health inequalities of these policies between 1997 and 2010, however, have only been partial, and even these small effects have been superseded by recent events such as austerity. Following the election of a Labour government on a mandate that included a commitment to reducing health inequalities and implementing evidence-based policy in 1997, the UK became the first European country in which policy-makers systematically and explicitly attempted to reduce inequalities in health. A raft of policy measures designed to reduce health inequalities were introduced since 1997 (as previously described), and, although the UK’s political system has become increasingly fragmented as a result of political devolution in Northern Ireland, Scotland and Wales, health inequalities have remained consistently high on policy agendas throughout the UK. However, despite having the most systematic policy around health inequalities in Europe, by the time Labour left office in 2010, mounting evidence indicated that local health inequalities in the UK and between the countries of the UK had not changed substantially, and in some cases had continued to get worse.

The key targets of the Labour government’s strategy were to reduce the relative gap in life expectancy at birth between the most deprived local authorities (called Spearhead areas) and the English average by 10% by 2010, and to cut relative inequalities in Infant Mortality Rate between manual socioeconomic groups and the English average by 10%, from 13% to 12%. The strategy failed to meet its own targets as the relative gap actually increased between 1995/97 and 2008 by 7% in terms of male life expectancy and by 14% in terms of female life expectancy. However, the relative gap between manual socioeconomic groups and the England average for Infant Mortality Rate actually fell between 1995/97 and 2007/09 from 13% to 12%, with a further fall to 10% in 2008/10.The latter represents a reduction in relative inequalities of 25%.The absolute gap also decreased from 0.7 in 1997/99 to 0.5 in 2007/09 with a further fall to 0.4 in 2008/10, an overall reduction of 42%. This suggests that regarding its own – albeit very limited – terms, the English health inequalities strategy was partially successful.

Table 6.2: Infant mortality rates in England, routine and manual socioeconomic group compared with national average (infant deaths per 1,000 live births)

Time Period Routine and Manual EnEnglish Average rate Absolute gap Relative gap
1997-99 6.3 5.6 0.7 13%
2002-04 5.9 5.0 0.9 18%
2003-05 5.7 4.9 0.8 17%
2004-06 5.6 4.8 0.8 16%
2005-07 5.4 4.7 0.7 16%
2006-08 5.3 4.5 0.7 16%
2007-09 5.0 4.4 0.5 12%
2008-10 4.7 4.3 0.4 10%
Change since 1997-99 -1.6 -1.3 -0.3 -3.0
% change since 1997-99 -1.2 -0.7 -0.5 -8.0

Another area of success of the strategy was around inequalities in ‘mortality amendable to healthcare’. Amenable mortality is defined as mortality from causes for which there is evidence that they can be prevented given timely, appropriate access to high-quality care.’ NHS funding was increased from 2001 when a ‘health inequalities weighting’ was added so that areas of higher deprivation received more funds per head to reflect their higher health needs. Analysis has shown that this policy -of increasing the proportion of resources allocated to deprived areas compared to more affluent areas — was associated with a reduction in absolute health inequalities from causes amenable to healthcare. Increases in NHS resources to deprived areas accounted for a reduction in the gap between deprived and affluent areas in male ‘mortality amenable to healthcare’ of 35 deaths per 100,000 and female mortality of 16 deaths per 100,000. Each additional £10 million of resources allocated to deprived areas was associated with a reduction in 4 male deaths per 100,000 and 2 female deaths per 100,000.

Death rates under 65 by area

Figure 6.2: Divide in under-65 years death rates between the 10% most and 10% least affluent neighbourhoods in England, 1920s to mid-2000s

However, when looking beyond these arguably rather minor changes in very specific areas (Infant Mortality Rate and mortality amenable to healthcare) and examining the broader social and spatial patterning of death and disease, health inequalities remained high, and indeed grew during this period. This is shown in Figure 6.2, which tracks trends in the size of the gap in death rates between the most and least affluent 10% of neighbourhoods for those aged less than 65 from the 1920s to the mid-2000s. The health divide between the richest and poorest areas had decreased until the late 1970s, but then increased since the 1980s and throughout the post-1997 years of the Labour government.

The most important reason for the very limited success of health inequalities policies in the UK since 1997 is the ‘lifestyle drift’ whereby policy went from thinking about the wider economic and social context to focusing almost exclusively on the individual-level, behavioural, compositional factors. The only very limited success of the English strategy is therefore because there is only so much that can be achieved by focusing on individual behaviour change or the provision of more smoking cessation programmes or by increasing access to healthcare services. While there were policies enacted under the 1997-2010 New Labour governments that focused on the more fundamental determinants (for example, the implementation of a national minimum wage, the minimum pension, and tax credits for working parents, and a reduction in child poverty) as well as significant investment in the NHS, there was, however, little redistribution of income between rich and poor individuals or areas. Nor was there much by way of an economic rebalancing of the country (for example, between North and South). Indeed, a senior Labour government minister claimed at the time that he was ‘seriously relaxed’ about people getting rich. Further, in wider policy, the New Labour governments continued the neoliberal approach of Thatcherism – including, for example, further marketisation and privatisation of the NHS.

Health inequalities policy was therefore overshadowed by the far more powerful, fundamental and politically driven trends in economic and social policy, both domestically and internationally, as a result of the rise of neoliberalism. The effects of these neoliberal economic and social policies on health inequalities have been stark (or of ‘epidemic’ proportions), and have meant that those at the bottom have fallen even further behind. In the face of such substantial (and largely unchallenged by what was previously a social democratic Labour Party) neoliberal structural changes to the fundamental determinants of health, the specialist area of ‘health inequalities policy’ (as outlined in this chapter) was unable to turn the tide on such longstanding health divides. It was therefore a case of ‘too little, too late’ – a lot of rhetoric and good intentions, but little in the end by way of meaningful action. The earlier post-war experience — in which smaller health inequalities were achieved through a more extensive welfare state and a different spatial and socioeconomic distribution of national wealth — and the results of the various policy reviews examined earlier in this chapter – do, however, provide clear evidence as to what is actually needed to really ‘turn the tide’ on health divides. The likelihood of such substantial change happening became even more remote with the election of the coalition (Conservative—Liberal Democrat) government in 2010 and then another Conservative majority government in 2015, both of which were committed to neoliberal-inspired austerity.

Coalition, (more) Conservatism and health inequalities since 2010

In 2008, a third policy review of health inequalities was commissioned, the Marmot Review. It was commissioned by a Labour government that was coming towards the end of its third term and was not enjoying public or media support. The government had also by this stage moved some way from its initial commitment to tackling the ‘upstream’ structural determinants of health, and was more focused on ‘downstream’ individual lifestyle factors. Within three months of being published in February 2010, a Conservative—Liberal Democrat coalition formed a new government. Indeed, the timing of the Marmot Review had ‘eerie echoes’ of the Black Report in the sense that it was commissioned under a Labour government but the decision to implement (or not) many of its recommendations had fallen to a Conservative-led government. Awareness of this political context may have influenced how the Marmot Review was drafted, possibly informing the decision to make rather vague and diluted recommendations that could be interpreted by, and remain acceptable to, different ideological perspectives, and thus avoid the political marginalisation that befell the Black Report in the 1980s. In addition, the international banking crisis and high levels of debt facing the UK meant that this was once again a period in which the government was committed to reducing public expenditure. It built on the earlier Black and Acheson Reports, although following 13 years of policy efforts to reduce health inequalities it had far more evidence on which to draw. Nevertheless, as Table 6.1 outlines, the Marmot Review’s policy recommendations largely mirror those of the earlier Black and Acheson Reports.

The coalition government accepted in principle the majority of the Marmot Review headline recommendations (all except the recommendations under heading 4, on income and poverty), and cited it as the basis for setting out a new public health system for England — in their 2011 White Paper Healthy lives, healthy people. This included the transfer of public health responsibilities from the NHS to local authorities with the establishment of Health and Wellbeing Boards (between, local authorities and local clinical commissioning groups [CCGs] of GPs), and the creation of a new organisation, Public Health England. In 2012, the government also created the Public Health Outcomes Framework, a set of indicators to monitor the new system that includes the aim of ‘reduced differences in life expectancy and healthy life expectancy between communities’. Under the new system, local authorities — via the Health and Wellbeing Boards were tasked with reducing health inequalities via actions on the local contextual and compositional determinants of health. This means that health inequalities and public health can now be ‘placed’ within broader local policies.

Public Health England was also created as a national body, and it has some responsibility for reducing health inequalities at the national level and between local communities. Its core mission is to ‘protect and improve the nation’s health and to address inequalities’. NHS England and CCGs, established under the Health and Social Care Act 2012, were also given a legal duty to reduce inequalities in access to — and outcomes from — NHS care. The Department of Health maintained a role in reducing health inequalities via its mandate with NHS England, and a framework agreement with Public Health England. The Secretary of State for Health is also required to ‘have regard to reducing health inequalities’. So now, in England, central government responsibilities for reducing health inequalities have been devolved to local authorities, the NHS and Public Health England, all of which have very limited powers to have an impact on the contextual or fundamental determinants of health (that is, the ‘rules of the game’).

In light of the new public health system set up by the coalition government in which local authorities have lead responsibility for reducing health inequalities, in 2014, Public Health England commissioned an independent inquiry to examine health inequalities specifically affecting the North of England, with a particular focus on how to reduce the North—South health divide in England (and, to a lesser extent, reducing inequalities in health within the towns and cities of the North), the Due North report. This concluded that the underlying causes of the North—South health divide in England and local health inequalities within Northern towns and cities were social, economic and political inequalities: differences in poverty, power and the resources needed for health; differences in exposure to health-damaging environments, such as poorer living and working conditions and unemployment; differences in the chronic disease and disability left by the historical legacy of heavy industry and its decline; and differences in opportunities to enjoy positive health factors and protective conditions that help maintain health, such as good quality early years education, economic and food security, control over life decisions, social support and feeling part of society. In order to tackle these root causes, the Inquiry set out four sets of recommendations (supported by evidence and analysis) to target inequalities both within the North and between the North and the rest of England. They focused on addressing:

(1) the economic and employment causes of health inequalities — calling for a regional strategy that ‘not only ameliorates the impact of poverty but also seeks to prevent poverty in the future, not least by investing in people, as well as investing in places’;

(2) the role of unequal early years in the development of health inequalities across the life course — calling for increased welfare support for families with children and for universal childcare;

(3) the need to share power over resources and to increase the influence that the public has on how resources are used to improve the determinants of health via the devolution of power within England; and

(4) strengthening the role of the health sector in promoting health equity as the NHS can influence health inequalities by providing equitable high quality healthcare, by directly influencing the social determinants of health through procurement and as an employer, and as a champion and facilitator that influences other sectors to take action to reduce inequalities in health.

Scotland, Wales and Northern Ireland maintained the pre-2010 NHS-based system with responsibility for reducing health inequalities lying solely with the healthcare sector — leading to increased divergence across the four UK countries in their approaches to health inequalities. In Labour-run Wales there has been little change, with a continuing focus on health promotion (as opposed to tackling health inequalities). Meanwhile, the restoration of powers to the Northern Ireland Assembly facilitated a fresh concern with public health, and a new Public Health Agency was established in 2009. The most significant developments, however, occurred in Scotland and England, where policies moved in very opposite directions. In SNP-governed Scotland (Scotland was led by a Labour-Liberal Democrat coalition from 1999 to 2007, and then the SNP from 2011), public health policy continued to articulate a social determinants approach to tackling health inequalities and that accepted the need for central government action. In contrast, the UK-wide Conservative and Liberal Democrat coalition government’s Public health White Paper for England paid little more than lip service to the wider social, economic, environmental and political determinants of health, choosing instead to stress that the causes of premature death are dominated by ‘diseases of lifestyle’ (compositional factors), for which the government accepts only limited responsibility. The lifestyle, individualised and very partial approach to health inequalities is continuing under the current majority Conservative UK government (elected in 2015).

What is to be done? Evidence-based health inequalities policy

So far this chapter has outlined how the UK governments from the 1980s onwards had an impact on health divides, showing a pattern of increasing inequalities despite (limited) action by the 1997-2010 Labour government. It has also alluded to what policy-makers and governments should do if they want to reduce health inequalities. However, this latter task is not reliant on mere speculation as the health inequalities reports commissioned by government agencies themselves over the last four decades — Black, Acheson, Marmot and Due North — provide an evidence base to underpin what could and should be done.

The four reports have much in common in terms of the explanations of the underlying causes of health inequalities: all four clearly state that health inequalities are a result of other societal inequalities and differences, and all take a ‘multi-causal’ approach to explaining their existence. Furthermore, they all emphasise the importance of considering determinants across the whole life course, not just the point at which health inequalities are most apparent, with emphasis placed on the early years of life. Indeed, the Marmot Review’s statement that it is the ‘cumulative effects of hazards and disadvantage through life’ that produce the social patterning of disease and ill health in the UK echoes almost precisely the Black Report’s conclusion that ‘inequalities in health tend to arise from the cumulative deprivation of a life-time’. Each places an emphasis on the social and economic (material) drivers of inequalities in health, although Acheson, Marmot and Due North drawing on the wealth of health inequalities research undertaken since the 1980 Black Report – also highlight the complexity of the way in which material factors often interrelate with various other determinants, particularly psychosocial determinants.

The Black Report was published before psychosocial theories had emerged as a credible body of academic work, and hence, unsurprisingly, does not refer to psychosocial determinants. The Marmot Review and Due North both place considerable emphasis on psychosocial explanations of health inequalities, giving issues such as isolation, a sense of control and individual and community empowerment far more prominence than in the earlier reports. Due North, however, is much more materially (and psychosocially) focused than either Acheson or Marmot in that it overtly rejects the role of behavioural factors.

Despite the existence of some theoretical differences between the reports, as described above, and a gap of almost 35 years, many of the evidence-based policy recommendations are remarkably similar. This section provides a brief thematic comparison of the main recommendations.

  • Early years and young people: For all four reports, the recommendations relating to early years bear striking similarities. While Black aimed for children to have ‘a better start in life’, with recommendations relating to increasing child benefits, improving pre-school childcare and providing free school meals, almost two decades later the Acheson Inquiry strongly echoed these recommendations. The Marmot Review is less directive, but as part of a policy objective to ‘give every child the best start in life’, various recommendations relating to maternal care, pre-school childcare and care within the education system are made. Similarly, the Due North report has ‘promote healthy development in early childhood’ as one of its four strategic recommendations.
  • Education, training and employment: The Black Report and the Acheson Inquiry both focused largely on pre-school services so the Marmot Review recommendation that reducing inequalities in education outcomes should form a central part of efforts to reduce health inequalities could be said to represent a new focus. The Black Report featured no direct recommendation relating to employment either. In contrast, the Acheson Inquiry highlighted the detrimental effects of unemployment, and suggested increasing opportunities for work and training. The Marmot Review continued the strong emphasis on employment and training opportunities, but supplemented this with an emphasis on the quality and flexibility of employment. Likewise, the Due North report highlighted the need for employment opportunities to be increased within the North, and for good quality early years education proportionate to need.
  • Working conditions/environment: The Black Report highlighted the need for ‘minimally acceptable and desirable conditions of work’. This was expanded by the Acheson Inquiry to include a call to address psychosocial work hazards. The Marmot Review further developed these concerns, placing particular emphasis on psychosocial-related issues such as equality and stress. All three of these national level reports recommend that the workplace be used an arena in which to undertake health-promoting activities. Due North does not talk about the work environment beyond a call for the living wage to be implemented.
  • Tackling poverty and redistributing wealth and resources: The Black Report put forward the ambitious aim of abolishing child poverty as a national goal for the 1980s, although it acknowledged that this was likely to be very costly, and also included a number of other recommendations (particularly around benefits) that were intended to tackle poverty. Fast forward to 1998, and while Acheson did not recommend such an ambitious goal, it, too, emphasised the need to tackle income inequality, specifically recommending that: ‘Further steps should be taken to reduce income inequalities and improve living standards of poor households.’ This focus is echoed in the Marmot Review, which recommends the implementation of a more progressive taxation system and the introduction of a minimum income for healthy living. The latter is also recommended by the Due North report alongside tackling child poverty and introducing a living wage.
  • Housing: All four reports call for an upgrading of housing stock. The Black Report focused on the quality and availability of local authority housing. The Acheson Inquiry added recommendations on fuel poverty and insulation and reducing accidents in homes, and placed particular emphasis on the housing of older people. The Marmot Review, less specifically, calls for the creation and development of ‘healthy and sustainable places and communities’, but in the longer term, it, too, calls for the ‘upgrade of housing stock’. Due North reflecting the rising housing crisis in the UK – calls for a licensing scheme to improve private housing stock.
  • The role of the NHS: All the reports stress the need for cross-departmental working at local and national levels of government. None of the reports suggest that the NHS can (or should) play a prominent role in addressing health inequalities, but the Black Report and Acheson Inquiry both make some recommendations concerning the need to ensure fair and equal access to healthcare services, and the Marmot Review suggests the ‘prevention and early detection of those conditions most strongly related to health inequalities’ should be prioritised. Due North highlights the importance of integrated local services and joint commissioning, and notes the role of higher funding allocations in deprived areas as a way of reducing mortality amenable to healthcare.
  • Empowerment and community control: As noted earlier, the Black Report pre-dated research into health inequalities that emphasised the role of psychosocial factors. The Acheson Report made recommendations about control at work. However, in the Marmot Review, social capital, described as the ‘links that bind and connect people within and between communities’, is presented as a ‘source of resilience’ and ‘a buffer against risks of poor health’. Related to this, the phrase ‘capabilities’ is used throughout the report to help illustrate the importance the review places on enabling individuals to have the opportunity to live fair and healthy lives throughout their life course. Due North goes even further in terms of having one of its four strategic recommendations to ‘increase the influence that the public has on how resources are used to improve the determinants of health’. It has the devolution of power from central to local government and down to communities as a central theme of the report.
  • Health behaviours: The first two reports also made some specific recommendations concerning the supply, marketing and consumption of tobacco products, whereas Marmot does not. None of the reports make similar recommendations for alcohol. In terms of diet and exercise, the Black relatively vague in suggesting that measures were required to ‘encourage the desirable changes in people exercise’. In contrast, Acheson made some rather specific recommendations, including increasing the availability of food to ensure the supply of ‘an adequate and affordable diet’. The Marmot Review is more similar to Black than Acheson, marking a return to relatively broad and unspecific suggestions such as ‘efforts to reduce the social gradient in obesity. Due North is very overt in rejecting the role of behavioural factors as an issue in the North—South health divide, and makes no recommendations in this area.

So these reports provide a clear policy agenda for what should be done to reduce health inequalities. However, as is clear in the review of actual policies from the 1980s outlined earlier in this chapter, the national policy effects of the reviews were minimal beyond leading to a welcome discourse around health inequalities. This is because good evidence alone does not lead to action — political support is required. The future politics of health divides in the UK and beyond is the subject of the final concluding, chapter.

The Health Divides website  enables you to compare characteristics of local authority and regions with each other, and against England averages.

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