Category Archives: Equality

The case for a new Beveridge Report

One of the last Labour Government’s real successes was to preside over an increase in life expectancy. In addition, the gap in life expectancy between the rich and poor decreased. Fast forward nearly 8 years, to March 2018 the Office for National Statistics published data showing that under Tory austerity the gap in life expectancy had widened. For women, the gap is the largest since the 1920s.

There is overwhelming evidence that these inequalities are not inevitable. They are socially reproduced. They can be changed. And that should give us all hope. But it needs political will to tackle them, not the soundbites of this Government.

In 2015, the International Monetary Fund stated that ‘widening income inequalities is the most defining challenge of our time’. Forty years ago, 5% of income in the UK went to the highest 1% of earners. Today it is 15%. According to the latest Sunday Times Rich List, the richest 1000 people in our society saw their wealth increase by 16% in the last year alone. This trend of increasing income inequalities has occurred in most high income countries, but some less than others.

Like Nobel economist Joseph Stiglitz’s, the IMF’s analysis showed that inequalities are a drag on growth and can also make growth more volatile. It showed that raising the income share of the poorest 20% of the population increases growth by as much as 0.38% over five years. In contrast, increasing the income share of the richest 20% by 1% decreases it by 0.08%.

The Organisation of Economic Co-operation and Development has also rejected ‘trickle down’ economics, so popular with Margaret Thatcher and her supporters, as the means of spreading income from the rich to the poor.

In spite of promises to tackle these ‘burning injustices’, according to the Equality Trust, Britain’s top bosses are paid, on average, 165 times more than a nurse, 140 times more than a teacher and 312 times more than a care worker. Indeed it would take a typical UK worker 160 years to rake in the average annual amount handed to a FTSE 100 boss.

The recent Equalities and Human Rights Commission report has revealed that the poorest tenth of households will on average lose about 10% of their income by 2022 – equivalent to £1 in every £8 of net income. This reflects other distributional analyses for example from the Institute of Fiscal Studies.

Reducing the gap between rich and poor is not just good for the economy. As evidence from The Spirit Level shows, life expectancy increases, as well as educational attainment, social mobility, trust and more. Fairer more equal societies benefit everyone.

In acknowledging the income inequalities that exist in the UK and the harm that this is doing to society as a whole, the question is what drives them and how to tackle them.

As Labour committed to in last year’s manifesto, we need changes to economic policy to address the unfair tax burden and poverty pay. But we also need to radically transform our social security system so that, for example, 8 million people currently in low paid jobs are not left living in poverty while they wait for pay improvements, and neither are their children. And if you become sick or disabled you should not be twice as likely to live in poverty as non-disabled people, as 4 million disabled people are now. Similarly, the state pension age for men and women shouldn’t be quietly pushed back, leaving increasingly frail, elderly people unable to work, subjecting them to live in poverty.

The 1942 Beveridge Report was the basis for a new welfare state set up after the Second World War, including the establishment of the NHS in 1948 and the expansion of social security. It was heralded as a revolutionary system that would provide ‘income security’ for its citizens ‘as part of a comprehensive policy of social progress’.

Since 2010, we have seen social security spending cut by nearly £34bn, with another £12bn planned by 2022. Spending on the NHS is barely keeping pace with inflation, and is falling behind countries like Germany, France, the Netherlands, Denmark and Austria.

We need a new Beveridge report for the 21st Century, defining a new social contract with the British people, addressing the poverty, inequalities and indignity millions of people, young and old, are enduring; bringing hope to a new generation as it did 70 years ago.

Of course these reforms need to be coupled with reforms to the current dysfunctional and increasingly precarious labour market as part of a coherent and comprehensive industrial strategy. Labour’s plans for a national education service that is not just about preparing you for work but is enabling you to get the most out of life, are also essential to tackle the structural issues that drive these income inequalities.

In addition to inequalities in income, inequalities in wealth, with land and property being the largest real asset, also need addressing. In 2002 it was estimated that 69% of the land in the UK was owned by 0.6% of the population. In the six years to 2011 the number of landholdings reduced by 10% but the size of these holdings had increased by 12%. So even fewer people own even more land.

Many in housing policy emphasise that if we’re to solve the housing crisis in addition to building more homes, we need to tackle the cost and availability of land and address the volatility in the market. With average house prices in the UK in 2017 at over £226,000 (over £496,000 in London), the Nationwide Building Society has estimated that it would take 8 to 10 years for people on average incomes to save the 20% deposit needed to buy a house and even longer for someone on a low income. Which means wealth inequalities are increasing even more.

And finally there’s inequalities in power. This is often the neglected inequality but is central to who we are as human beings. Power is complex. It is about having influence, control, even authority. We usually think of this as associated with having money or ‘corporate power’. But it is also about position and status. In who makes decisions and how. Whether corporate or other unaccountable, ruling elites, the dangers are clear. Elites exclude and marginalise, enabling prejudice and discrimination to thrive, and trust in others, in difference to suffer as a consequence.

Inequalities are not inevitable but to tackle them in all their forms takes commitment, it takes courage and it takes leadership.

First published on Debbie’s website 

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It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.

Smoking

Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

Obesity and malnutrition

I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

NHS funding

Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

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1) Holistic care:

Mental health and social prescribing services are doing their best in our practice area but are massively under resourced. Don’t forget the critical importance of valuing continuity and teamwork in the primary care team – really important for safeguarding, morale and retention of staff. See Watton in BMJ, especially around Health Visitors and District Nurses within practice teams. Same points apply re social prescribing / CSW / Health Trainers

Due to the clear correlations between deprivation, psychosocial problems and physical health, it is a false economy not to invest in mental health and social prescribing as ultimately patients fall back on more expensive NHS services. Many of our patients are illiterate or have poor health literacy and so patients often fall through the gaps of traditional appointment systems with letters and phoning back to make appointments even if they are in the correct age range (which many are not as they are too young or housebound). Many of our patients are struggling due to being victims of emotional, physical or sexual violence: their anxiety can be displayed as anger or addiction.

Improving Access to Psychological Therapies

It is fantastic to have IAPT counsellors in the building (as you know many patients do not attend other sites) but due to the constraints they are working under often our patients living in the most deprived area of Sheffield do not fit the criteria as they can be chaotic or ‘not ready’ for the emotional challenge of counselling.  I wonder if a more flexible type of approach could be taken, many of our patients need to build up trust with professionals over serial encounters before being able to engage – the IAPT triage service doesn’t allow for this, sadly. 

Groups or lectures are on offer around the city but our patients struggle on many levels to attend these due to poor self esteem, confidence and practical issues such as buses, school pick up and travel costs.

I also wonder if a ‘trauma therapy’ approach may be more useful for our patients as I heard about this from another Deep End GP in Glasgow.

In summary there are great counsellors and charities working in our area doing outstanding work beyond their resources but it is insufficient due to the massive need on the our, patients fall through the cracks and this perpetuates poor health and greater pressures on NHS services. Investing more to support mental health services and social prescribing feels right on a moral and financial level to reduce inequalities.

 2) Families and Children:

The links between early childhood experience and brain development has long been known and the field of epigenetics is emerging.

The local family planning clinic has been closed. We predict that unwanted pregnancies will go up in our area. We think investing in sexual health and contraception services, educating girls and women would help inequalities. Early years are crucial yet we have had the team dismantled – the overstretched health visitors are no longer in our practice. When I was a trainee in 2002 the health visitors knew all the families and who to worry about, came to all the practice meetings and we also debriefed over the kettle (a very underestimated source of support and sharing ideas and information!).  Not having the health visitors in our practice feels like a serious threat to safeguarding.

My suggestion would be to get the health visitors and district nurses back in the practices and integrated in the teams – we need more of them too! We need more support to provide contraception, sexual health services and parenting sessions.

3) Multimorbidity & Complexity: 

Again the links between deprivation and complex medical problems and multi morbidity at a young age have been proved and we need help to support our patients with these.

There has been a fantastic collaboration at The Whitehouse for many years between Prof Heller the diabetologist and the primary care team; once a quarter Prof Heller and his specialist nurses come for lunch and a cuppa at the practice and the Multidisciplinary team present our patients with Diabetes for a case discussion. These are complex patients who often won’t attend hospital outpatients. This opportunity of case discussion is so valuable on many levels. It builds personal relationships between primary and secondary care which allow a 2 way flow of information, education and morale essential to providing high quality care to patients. Our patients are not only suffering serious physical problems but the case discussion also allows us to acknowledge their complex lives and histories.

We have also been lucky enough to be part of a pilot with joint clinics between a Paediatric Registrar and GP trainee: this has been shown to reduce out-patient appointments and again develops supportive educational relationships.

We particularly need help with patients who have persistent pain and addiction to prescription drugs – experienced physiotherapists who are aware of issues surrounding deprivation would be a real asset to decreasing inequalities, as this could improve people’s chances of getting back into work and improve quality of life.

More educational cased based discussions between primary and secondary care specialists are fantastic educational opportunities and are invaluable to give the best patient care: Could we have more specialists coming to the practice like Prof Heller? It must be cheaper than running an out patient clinic and studies show that it does reduce referral rates and improve the quality of referrals.

4) Lifestyle: Smoking and getting more active.

We would like our stop smoking service back in the practice! Patients are reluctant to go to the ‘pharmacy’ for this, even though it is relatively close by.

We have recently been in discussion with SIV to see if our patients can have more support in our practice building to get more active and build confidence to going to other venues with someone they trust. The barriers to exercise are complex: one of my patients has flash backs to being raped by her brother and father when her heart rate goes up; another after being raped wanted to make herself obese so no-one would ever fancy her again.  Our patients need kind, broad shouldered, flexible and good humoured health trainers to overcome these barriers.

Health trainers working in house with physios would be really helpful to reduce inequalities.

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Introduction

This is the first in a set of two blogs attempts to describe the story of health inequalities in a town and recent history, why this remains important, what a strategy might look like and how it might be framed.

Blog 1 considers the story in Sheffield to date, framing, context and language, the impact of systematic strategy.

Blog 2 will cover general approach to intervention and specific actions or interventions we should implement.

Blog 3 will cover the perspectives of two jobbing GPs working at the sharp end of this

Blog 4 will cover some thoughts on where next

I’m sorry it’s a bit long and complex ………

  1. The story in Sheffield to date

How do we do?

Inequalities in health outcomes in Sheffield are well documented: there is a 20 – 25 year gap in healthy life expectancy between best and worst along the normal dividing lines of deprivation,  mental health, learning disability, ethnicity, etc.  The Marmot indicators, which outline this in more detail, can be found here.  They were replaced in 2016 by the PHE Wider Determinants Tool.  This includes a “Marmot Indicators” domain.  This paper will not discuss these further for brevity.

The current strategy for Sheffield

Sheffield has a Sheffield Health Inequalities Plan agreed in 2014.  The plan was lifted straight from the Joint Health & Wellbeing Strategy (JHWBS) and is made up of all the recommendations in the JHWBS that refer to health inequalities.  The JHWBS itself arose from the JSNA.  It wasn’t something separate and different: putting health inequalities into a separate plan was supposed to make us all focus explicitly on health inequalities.

In retrospect, most seem of the view that it didn’t achieve that objective; something similar could be said of the JHWBS.  It’s a little old now, and all acknowledge there is a need to revise or rewrite it.  We all know that health inequalities as one of its most important priorities.  We mostly accept there are no simple easy solutions.

The Sheffield HWBB has held two recent discussions, in December 2015 and June 2016.  The December 2015 meeting focussed on quantifying the challenge, while the June 2016 meeting focused on agreeing a refreshed strategy; building on the 2014 plan.  In June 2016 there were five areas of focus, reflecting a need for interventions with a short and long term return:

  • Continued commitment to an asset based community development based approach to health and wellbeing
  • Continued investment in and commitment to primary care and within this General Practice services, especially in the most disadvantaged parts of the city
  • Continued commitment to the principle of implementing effort and change where greatest need is identified
  • Refocused effort on the link between employment and health
  • When looking at “healthy lifestyles” focus on the environment and make the healthy choice the easiest and default choice.

Clearly these  five areas highlighted were not the only answer to the difficult issue of health inequalities; rather, these were the areas where the Board agreed to focus first.

The Board also requested that emphasis be given to the concept of moving from an equal offer to a differential offer with a view to achieving an equitable outcome.  This implies a tailored response to greater need.  Finally it’s important to recognise the set of things that can be changed at Sheffield level whilst recognising the continuing need for on-going pressure for national change.

It’s not just about deprived geographical communities

A focus on both geography and specific population groups is needed.  The geography issue is broadly a point about socioeconomic deprivation, but it is important to note that this is not just about “the poor” but other excluded groups as well.  Other important groups include homeless individuals, prisoners, sex workers and people with substance use disorders, to name just a few.  Of course, these populations can overlap: for example, substance use disorder is common in other socially excluded groups.  There are many other groups with substantially poorer outcomes than the population average.

The Board also identified that specific population groups require additional focus including, for example: children and young people, BME groups, those with learning and physical disabilities and those experiencing mental health problems.  This was a specific issue around vulnerable groups of people, including but not limited to the protected groups identified in equality legislation.  The advantage of a double and layered approach is that it allows for multiple inequalities to be handled at the same time.

There is a wider context

The three themes of Due North (Poverty and economic inequality; Healthy development in early childhood; and Share power over resources and increase public influence over decisions) are still pertinent.  The Due North analysis is essentially a socio-economic one which builds on this to make the case that economic inequity leads to alienation.  Due North argued for the need to  strengthen the role of the public sector and tried to address the complexity in this by talking to three different agendas (regionalism and government structures, greater transparency of decision making at a local level and collective forms of ownership).  Arguably Due North was weak on the role of the community and voluntary sector, especially grass roots community organisations.

There is a much broader context across the city also.  The single biggest factor driving the health gap in the UK is the wealth gapThere are also substantial work streams around issues of direct relevance to health inequalities: work on inclusive growth, the Fairness Commission, and SCC’s/City work on poverty, to name just a few.  Relevant strategies in other policy domains are in place, but these may be partial and disconnected – financial security, community stability, community coherence – all need to be pulling together.

  1. Why it remains important
  • Injustice in itself;
  • Social cohesion – Marmot suggests that in societies with substantial inequality the considerable gap between the top 1% of income earners and the rest of society threatens social cohesion;
  • Important factor in the slowing down of improvements in Life Expectancy and Healthy Life Expectancy;
  • HWBB (and the partners involved) has a legal requirement to address inequality in access and outcomes – See here.
  • Not addressing demand will lead to costs to the state that are unfunded and storing up problems for the future. This can be thought of as addressing diabetes vs obesity vs the determinants of obesity;
  • This is NOT a side issue, it is a population issue. Inequalities are bad for ALL of us – we’re ALL worse off as a consequence.  It’s not just about the most deprived.  Inequality is a societal issue: when expressed in terms of the economy, inequality is a drag on total societal production.  The same may well apply to wellbeing, such that inequality in wellbeing is a drag on total societal health and wellbeing.  Societal health and wellbeing is then a driver of demand for services;
  • It is not only a public funding issue but public funding is an important social protection and source of investment in things the market won’t provide.
  • From an NHS perspective, inequity in morbidity (and multi morbidity) is driving demand, expressed in terms of consequences for the health care system, with a 15 year differential between the most and least deprived in the onset of multi morbidity. We can document this in Sheffield and it is a driver of demand for public services. I’d encourage readers to consider my take on the  the most important charts in health care, particularly chart 2, 3 & 4. This is where the demand in your health and social care system is coming from. I’ve blogged on that. A lot. And won’t repeat all that here
  1. Why has there been limited to no progress?

Nobody underestimates the difficulty of moving some of these debates forward, because there are no easy or simple answers.  Measurement is easy and talk is easy, but concrete progress is difficult.  Reasons for this limited progress include:

  • There isn’t a burning platform for the issue that everyone aligns around – the money. Whilst there’s  a platform around social justice, amongst other things, this is not connected to the demand and resource implications of inequalities; Addressing health inequalities is not seen as mission critical to the business.  There isn’t a “business case” clearly written and articulated on it.  However, until we sort out wealth inequality there is limited/to no point talking about economic productivity;
  • Differential resourcing is very difficult, politically and operationally;
  • The wider context is exceptionally challenging. We are facing the most challenging outlook for public services since the 1970s.  Pre-Brexit, the signals were that austerity would continue into the 2020s; post-Brexit, no economics textbook in the world says that a decade of uncertainty is a good thing.  This has clear implications for public services that are incredibly dependent on the economic cycle.  Austerity is certainly making inequalities worse not better, through direct impacts on individuals and the indirect result of cutting the social security safety net.  It has been well documented that the impact of austerity is worse in areas that are more deprived ([1],,[2][3]).There is also a layering effect of multiple cuts on families.  The 40% Local Government cut will and is directly affecting the things that determine health of individuals and communities (such as the closure of Surestart Centres).  We can’t keep cutting and expect nothing to happen.  It would appear that both quality and length of life is deteriorating as we get deeper into the impact of austerity;
  • Beyond austerity, the resource allocation formula itself has created inequality;
  • Governance: the current challenge needs stable long term government.  We have a minority government: history (1970s) suggests it will last, but that the government will be thinking in days and weeks, not months, years or decades.  There is a need for a fundamental realignment of systems but in a minority government, the overriding mind set will be “is it contentious?”  Realigning priorities is contentious and thus likely to not happen.  At the local level, governance is messy, with differential levels of devolution, financial challenges and limited stability.  Grenfell Tower is an obvious and emblematic tragedy and profound in governance terms.  It has challenged all of us as we have created an “efficient” delivery system through outsourcing leading to fragmentation where nobody is in control, and leaders have no line of sight and no real control.
  1. Language and framing of health inequalities. It matters

There is value in being clear about how we understand and talk about the issue that is health inequalities, including the words and framework we use.

The issue could be Framed around the following domains (not necessarily in order of importance before anyone gives me grief):

  • Our health behaviours and lifestyles
  • Wider determinants of health
  • Communities and health
  • An integrated health and care system

The Marmot areas of recommended policy focus remain the benchmark:

  • Enable all children, young people, and adults to maximise their capabilities and have control over their lives;
  • Create fair employment and good work for all;
  • Ensure a healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities;
  • Strengthen the role and impact of ill health prevention.

It may also be framed around life course (starting well, living well, ageing well) and in terms of services for people and places where people live. 

There is also merit in bringing together the various strands around equality, poverty, inequality and similar as many of them cover similar space

What words do we use matter

The language of “health inequalities” might benefit from simplification: Consider the impact of “health inequalities” vs “poorer health and shorter lives”.  There is a need for language that communities really engage with.  The Robert Wood Johnson Foundation have done some interesting work in this space, as have the Frameworks Institute, specifically here.  In discussion with residents, there will likely be a focus on their priorities relating to the here and now.  Getting public focus on health inequalities might take some doing.

What framework do we use?  Julia Lynch makes the case of the danger of “medicalising” or individualising heath inequalities:

ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.  Medicalizing inequality is appealing to many, more appealing than tackling income and wage inequality head-on.  But it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve.  Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities”.

Similarly Marmot points out that evidence on “tackling” health inequalities tends to be focused on the biomedical model paradigm and evidential thinking.  Marmot recently noted that “downstream” interventions have been covered, for the most part, in the scientific literature.  There has been much less focus on structural interventions.

If one went purely by the numbers of papers published, one would put effort into pharmacological treatment and would ignore housing; emphasise case management and ignore poverty”.

We need to be clear that “Health” does not mean the same thing as “the NHS”.  We should define the differences between “Health”, “NHS” and “Social Care” vs “Health” and “Wellbeing”.  Using the narrative being promoted by Prof Burns on salutogenesis (what causes good health) vs pathogenesis (what causes ill health) could help.

Determinants are not inequalities and vice versa.  The term “determinants” is one way of expressing the risks to health and wellbeing.  They are upstream risks, assets or protective factors.  Both upstream and downstream factors matter, but we should start from the position that upstream factors matter more.  Inequity is the differential distribution of these factors.

Health inequality is therefore about:

  1. The unequal distribution of clinical and lifestyle risk factors (a small part of which is about the NHS)
  2. The unequal distribution of social and environmental risk factors (the determinants)
  3. The determinants of the determinants (power, concentration of wealth, dominant economic model etc.)

Health inequalities are not a “health” thing, or indeed a “public health” thing.  The consequences of “health inequalities” are social and specific to the NHS only in terms of demand.  Some argue in this context that the Department of Health & Social Care is the wrong sponsor agency, as it is responsible for the consequences of failure rather than the solutions.  There is also a danger that DHSC sponsorship will tend to lead to health service design solution thinking first.

The causes are largely upstream of the NHS.  There are local, regional and national aspects to the solutions, especially in terms of skilled advocacy and challenging conversations with other parts of government, and the economic, social and political ideologies that make the inequitable distribution more likely: the determinants of the determinants.

  1. The impact of a deliberate strategy: is it worth the effort?

Yes.

From a number of viewpoints. If you don’t care about social justice and important stuff like this, and only care about demand for services and money – I’d encourage you to very carefully consider the last two bullet points in section 2 above. This directly links inequality to demand, and illustrates why it’s not just a soft fluffy social policy issue.

Barr highlighted the positive impact of a deliberate strategy at national level, considering geographical health inequalities measured as the relative and absolute differences in male and female life expectancy at birth between the most deprived local authorities in England and the rest of the country.

The analysis suggests that prior to the introduction of the English Health Inequalities Strategy, geographical differences in life expectancy and health were widening.  During the implementation of the strategy, these trends were reversed but since this program ended there is evidence to suggest the improvement is being undone.

The period of the strategy encompassed a time (up to 2008) of increased public spending, economic growth and stability, relatively low unemployment, and increased investment in both healthcare and programs that addressed the wider determinants of health.

There was not always a clear distinction between policies that were part of the health inequalities strategy and policies that would have happened anyway in the absence of the strategy.  However, this period of increased social investment across the whole of government, targeted at disadvantaged areas and groups, was associated with a decline in health inequalities and geographical differences in life expectancy.

The end of the strategy and the start of the austerity program which reversed many of the key policies occurred at the same time, and therefore the effects of the program ending and austerity starting cannot be separated out.  However, there is clearly a stark contrast between a time when investment in policies which addressed the wider determinants of health resulted in a reduction in geographical differences in life expectancy and health, and the current policy environment which may be reversing those trends.

The reductions in the gap between best and worst were circa 1 year, which is hugely significant given the population nature of life expectancy. Think of the number of life years involved in such a change in life expectancy, then think about the morbidity – and thus lost productivity economically speaking and heath / social care use that preceeds  death.

References.

1 See here for evidence in strong gradient  in correlation between LA cuts and deprivation local authority level analysis from CRESR report (those with most need in population worst affected)

2 See here for impact of welfare reform split in other ways from Equality and Human Rights Commission report

3 See also Liverpool John Moores – Welfare reform, cumulative impact analysis 2017

First published on the Sheffield DPH blog

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How do early circumstances influence us later in life? Previous studies have found that socio-economic factors in early life can continue to have persistent impacts throughout one’s life and, coupled with circumstances in adulthood, jointly contribute to later health. Understanding these influences can therefore be beneficial to policies aiming to reduce health inequalities. This is why studies using longitudinal data, and especially those sampling a specific cohort, are particularly useful in disentangling the relationship between early life and later health.

The 1958 British National Child Development Study (NCDS) makes available rich data, ideal for this line of study. The NCDS has followed over 17,000 individuals born in 1958 for 50 years, providing information across different domains (e.g. physical, social, and health) and at different stages in life. Yet socio-economic circumstances are difficult to measure in practice, because they are multi-dimensional and sometimes unobserved. So, how can we represent complex pathways by realistic statistical models?

Our research proposes a structural model that connects the socio-economic circumstances in childhood, partnership history in adulthood, and health in midlife (Figure 1). Around 50% of individuals in our British cohort (currently in their 60s) grew up in families with unfavourable conditions in at least one of the four dimensions of socio-economic circumstances that were identified in the early phases of the study.

Effects of childhood circumstances

Figure 1: Path diagram showing the effects of childhood socio-economic circumstances (SECs) on later health

Having performed the analysis, we are able to formulate four sets of conclusions.

  1. Do childhood socio-economic circumstances directly influence midlife health?

We find that the estimated effects of father’s social class, financial difficulty, and material hardship in childhood on midlife health to be significant and similar in magnitude, before and after controlling for partnership experiences. This suggests the influence of these factors during one’s childhood are long-lasting and persistent, and that those with unfavourable conditions in these aspects are significantly more likely to be in poor health at age 50 (Figure 2).

Figure 2: Predicted population-average probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

 probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

Note: Marginal probabilities are computed keeping all the other covariates fixed at their observed values for each individual. Individual-specific random effects are simulated from the estimated distribution.
  1. Do partnership experiences influence midlife health?

We find that individuals who have formed their first partnership later in life tend to have a lower risk when it comes to developing health issues at age 50. Also, among those who have started the first partnership at the same time, cohort members who have spent longer time single before the age of 50 have a higher chance to be in poor health in midlife.

  1. Are there any indirect effects of childhood socio-economic circumstances on midlife health?

The results suggest that an unstable family structure in childhood pushes up the likelihood of poor midlife health but the effect is not directly transmitted: rather, only through an indirect path via one’s own partnership experiences. We find that unstable family structure significantly increases the likelihood of the early formation of first union and that of subsequent dissolutions.

Back to the health submodel, cohort members who formed the first partnership early are significantly more likely to be in poor health in midlife, and those with shorter partnership episodes, i.e. those who spent a higher percentage of time single, have a relatively higher risk to develop health issues at age 50. The evidence confirms the hypothesis that the influence of childhood socio-economic circumstances on midlife health is partially mediated by partnership experiences.

  1. Do different partnership experiences share common influences not captured by observed characteristics?

Our analyses find that such shared influences do exist. Certain individuals who form their first relationship early tend to be less likely to suffer a relationship breakdown. In the future phases of the study, we will investigate the individual-specific characteristics relevant to this correlation – such as whether those with a mutual interest in being in a quality relationship tend to maintain the union, lowering the risk of separation.

First published on the British Politics and Policy blog

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‘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 …

Conclusion

  • 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 www.equalitytrust.org.uk/support-us 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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