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    In the 1976 film All the President’s Men, the informant, Deep Throat, advised the investigative journalists, Woodward and Bernstein, to “follow the money” if they wished to get to get to the bottom of what was going on. And the same advice is likely to apply if we are to evaluate national and local government policy priorities in addressing inequalities.

    The vast bulk of public spending in Wales is undertaken by local health boards and local authorities. Probably correctly, the Welsh Government has decided that “big is best” in terms of the size of the these bodies to delivery these services.

    Whatever the advantages in bigger delivery bodies they can can create problems in terms of transparency and public accountability as power is concentrated further from communities and citizens. And as our public bodies become bigger and more centralised “following the money” becomes more and more difficult.

    A substantial amount of Welsh Government funding is allocated to our health boards and local authorities through needs based formulae. But once the money makes its way to these bodies it is very difficult to monitor if it is being spent in line with the allocation principles. And as these recipient bodies get bigger this task becomes even more difficult.

    Local authorities in Wales do not like hypothecation of Welsh Government funds. They wish to be free to make local decisions in line with local needs. But the methodology of resource allocation at a local level is often very opaque and it is very difficult to hold our councils to account in terms of their spending priorities.

    In this era of austerity there is no doubt that our most disadvantaged citizens and communities are bearing the heaviest burden. The Welsh Government is working hard to mitigate this though a range of policies but it is crucial that this intention is mirrored where it really matters — at the front-line grass-roots level.

    At the end of the day it is outcomes that matter most and it is excellent that programmes such as the Foundation Phase and Flying Start are subject to regular independent evaluation. But in many cases evidence of outcomes can take some time to emerge. In these situations intermediate or proxy measures have to be used and resource allocation ( qualitatively and quantitatively) is often an important guide.

    Our most vulnerable citizens and communities are more dependent on public services. They are therefore the most vulnerable when vicious austerity programmes are being implemented. It is vital that effective means are put in place to make sure that our reduced levels of public investment goes to where the need is greatest. Our public bodies must have clear and transparent funding streams in place and that both local and national scrutiny take place to ensure that best outcomes are delivered.

    Welsh Health boards cover populations from 132k in Powys to 678k in Betsi Cadwallader. Within health boards 4% of Powys’ population is in the poorest 20% compared to 39% in Cwm Taf and 27% in ABMU. But do we know that within these health boards that resources are allocated in line with this level of need at a local level?

    In the recently published policy on primary care workforce, A Planned Primary Care Workforce for Wales, the Welsh Government has highlighted the importance of the emerging 64 “primary care clusters” as a basis for health care planning. These clusters have a population size between 25k and 100k. They are therefore a more sensitive unit size for health care planning on the one hand but also for measuring the level of health care investment and outcomes. Some work has already started on this and the Workforce policy is committed to building on this.

    As this information becomes more available it is important that Health Boards “follow the money” and resources to ensure that their allocation is in line with needs and is producing the required outcomes.


    There are clear links between childhood poverty and adult health. Even if one manages to escape from the situation of poverty as one grows into adulthood, a disadvantaged start in life can leave lasting health problems, both physical and psychological. Studies have shown that children living in poverty are less healthy in nearly every way than those in well-off families, and even small differences in economic and social status can have a significant effect on childhood health.

    Disadvantaged from the start

    Statistically, poor mothers are more likely to have underweight babies, and as their children grow, they are likely to be an average of three centimetres shorter than their better off counterparts. This is not genetic, but a failure to reach full height potential caused by factors such as inadequate nutrition and unsuitable living conditions.

    As well as this initial handicap, poor children are also far more prone to such conditions as respiratory and gastrointestinal infections, nutritional deficiencies, dental problems and impaired eyesight. Again, nutrition and living conditions are mostly to blame, as poor families struggle to afford consistently healthy food in adequate amounts, and often live in homes that may be cold, damp, affected by mould and so on. Healthcare and suitable clothing are also harder to afford.

    Psychological, emotional and developmental disorders should not be discounted either, often caused by the family stress that is an inevitable result of economic hardship. Finally, we must not forget that poor children likely live in a harsher environment with fewer basic amenities; statistically they are more likely to suffer childhood injuries in accidents.

    The link to adult health

    Medical conditions such as asthma, acquired in childhood, are hard to shake off even when one’s living situation is greatly improved. Similarly, physical strains on the young body can weaken it for life. Many disadvantaged children do not manage to escape the poverty trap and so remain poor and unhealthy. This obviously puts greater strain on the health service, with higher costs and higher numbers of individuals requiring more care in later life.

    Tackling child poverty in the UK

    Successive governments have vowed to combat or eradicate child poverty in the UK. In 1999, Tony Blair pledged to end child poverty in a generation by moving more families off benefits and into work. The coalition and current Conservative governments have adopted similar strategies, emphasising improvement to educational opportunities and living standards alongside encouragement to work full-time.

    Nevertheless, charities such as the Prince’s Trust have taken up much of the burden. The Trust helped over 750,000 young people turn their lives around between its beginnings in 1976 and 2013. It is helped in this work by a number of generous donors, including Lord Laidlaw. Laidlaw has donated over £2m to the Trust. He also founded the Laidlaw Youth Project in 2004 to help disadvantaged youngsters in Scotland. Lord Laidlaw believes education is the best way out of poverty and has supported several Scottish schools as well as providing scholarship funds to universities.

    There can be no doubt that poverty is linked to poor health, especially for children. Health problems in childhood can blight one for a lifetime, to the detriment of society as a whole. It is in all our interests to make childhood poverty history.

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    by Ted Schrecker and Clare Bambra

    Within the small local authority of Stockton-on-Tees in the North East of England (population 192,000), the difference in male life expectancy between the most and least deprived areas is 17 years – comparable to the difference in average male life expectancy between the UK and Russia or Senegal.  In Washington, DC around the turn of the century, the difference in male life expectancy between the poor (and predominantly black) southeast of the city and the wealthy, overwhelmingly white suburbs in Maryland was even larger (20 years).

    These health inequalities reflect underlying social and economic inequalities.  Since the early 1980s, neoliberalism or “market fundamentalism” has dominated discussions about politics and economics across much of the globe.   In our book Neoliberal Epidemics: How Politics Makes Us Sick  we consider the health effects of over three decades of these policies with particular reference to the US and the UK. We identify four neoliberal epidemics: austerity, obesity, stress, and inequality.  They are neoliberal because they are associated with or exacerbated by the rise of neoliberal politics. They are epidemics because they are on such an international scale and have been transmitted so quickly across time and space that if they were a biological contagion they would be seen as of epidemic proportions.

    Addressing the 2014 annual joint meeting of the World Bank and the International Monetary Fund, the Fund’s managing director Christine Lagarde described the growth in inequality worldwide as “staggering”. Its dimensions in the US and the UK certainly merit that description, largely due to increases in the income and wealth share of the top 1%. In 2014, it was reported that the combined wealth of the 104 richest individuals living in the UK amounted to more than £301 billion, and that the wealth of the UK’s five richest families alone exceeded the net worth of the bottom 20 percent of the population.  In the US, the share of the nation’s wealth of the top 0.1 per cent (one one-thousandth) of the population increased from 7 percent in 1978 to 22 percent in 2012 – comparable to the inequality of distribution before the Great Depression, and roughly equal to the net worth of the bottom 90 percent of the population, which had fallen from 35 per cent in the mid-1980s to 23 percent.

    This trend partly reflects growing inequalities in market incomes (wages, salaries, bankers’ bonuses, stock options and investment income). However in the UK and especially in the US, the growth in the income share of the top 1% that began circa 1980 is also a result of sizable reductions in the marginal income tax rate for top earners.  The main beneficiaries were the richest 1% of the population. In the UK, the Gini coefficient – a key measure of income inequality – rose rapidly throughout the neoliberal Thatcher era, and has not fallen substantially since then. Perhaps not surprisingly, on some measures health inequalities between the richest and poorest local authority districts in England were larger than at any point since before the Great Depression even before the financial crisis. And while most people are only just recovering from the effects of the 2008 financial crisis, or are falling farther behind, the wealth of Britain’s richest thousand families has doubled.

    In The Spirit Level, epidemiologists Richard Wilkinson and Kate Pickett concluded that high levels of inequality have negative health effects throughout entire societies, although multiple causal pathways are involved.  For example, life expectancy and infant mortality are correlated with the level of income inequality across high-income countries and, within the US, across states.  Five years after their book was published, the evidence appears even stronger. Meanwhile, the deepening economic inequality promoted by neoliberal societies has greatly reduced social mobility so that your parents’ income, job and education now determines your own future social position and health to a greater degree than at any point since the second world war, at least in the UK and the US where social mobility has declined since 1980.

    Today’s high levels of inequality in countries that have travelled the neoliberal road are the result of political choices – choices that could have been made differently.  Geographer Danny Dorling points out that similar trends have not occurred in many other high-income countries, such as the Scandinavian countries with social democratic welfare regimes. “Only some rich countries recently set out to become more unequal”.  And the illustration shows that in high-income countries the proportion of people living in poverty, on a measure designed for such cross-national comparison, varies threefold.  This is not a reflection of differences in market incomes, but rather of political choices about how the product of a society’s economy, and its accumulated wealth, should be distributed.  Rather than being a fact of economic or political life, inequality is a neoliberal epidemic: one of the ways politics makes us sick.

    Poverty rates before and after taxes and transfers, selected OECD countries,

    Poverty rates before and after taxes and transfers, selected OECD countries

    2012 (except as noted)

    Links: Schrecker, T. and Bambra, C. (2015) Neoliberal Epidemics: How Politics Makes Us Sick, Palgrave Macmillan, available at:

    About the authors

    In June 2013, Ted Schrecker moved from Canada to take up a position as Professor of Global Health Policy, Centre for Public Policy and Health, Durham University (UK). Since 2002, most of his research has focused on the implications of globalization for health; he also has long-standing interest in issues at the interface of science, ethics, law and public policy. A political scientist by background, Ted worked as a legislative researcher and consultant for many years before coming to the academic world, and co-edits the Journal of Public Health. Among his publications, he is editor of the Ashgate Research Companion to the Globalization of Health (2012) and co-editor of a four-volume collection of key sources in Global Health for the Sage Library of Health and Social Welfare (2011). Ted can be followed on Twitter @ProfGlobHealth.

    Clare Bambra PhD is Professor of Public Health Geography and Director of the Centre for Health and Inequalities Research, Durham University (UK). Her research focuses on the health effects of labour markets, health and welfare systems, as well as the role of public policies to reduce health inequalities. She has published extensively in the field of health inequalities including a book on Work, Worklessness and the Political Economy of Health (Oxford University Press, 2011). She contributed to the Marmot Reviews of Health Inequalities in England (2010) and Europe (2013); the US National Research Council Report on US Health in International Perspective (2013); a UK Parliamentary Labour Party Inquiry into international health systems (2013), as well as the Public Health England commissioned report on the health equity in the North of England: Due North (2014). She is a member of the British Labour Party and can be followed on Twitter @ProfBambra.


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    “Some people believe football is a matter of life and death,” Bill Shankly, Liverpool FC’s manager between 1959 and 1974, once said. “I am very disappointed with that attitude. I can assure you it is much, much more important than that”. Now imagine the newspaper headlines if at the end of the football season three of the biggest English football clubs – Manchester City, Everton and Liverpool – were relegated from the league. If football were really a matter of life and death, this is exactly what would happen.

    We put together a public health league table which ranks the areas local to the 2014-15 Premier League football clubs from best to worst using key health indicators with a corresponding code: the percentage of smokers (P, played); weight – percentage of obesity and overweight (W, won); deaths – all cause mortality rates per 100.000 (D, drawn); life expectancy for males in years (L, lost); female life expectancy in years (F, for); alcohol-related hospital admissions per 100,000 (A, against); and the gap or difference in life expectancy for men between the most and least deprived areas of the local authority in years (GD, goal difference).

    The final league points represent the sum of ranks for each outcome. For example, Chelsea’s league-winning score of 114 points comes from ranking second for P, first for W, D, L, F, and A and last for GD.

    Public Health League

    While Chelsea would still be winners in the public health league table, Crystal Palace, Manchester United and Tottenham Hotspurs would join them in the top four, with West Ham in fifth place. As the bottom three in the table, Manchester City, Everton and Liverpool are all relegated.

    The data we used came from PHE Outcomes Framework Data, the Office for National Statistics and the Public Health Observatory Wales. Premier League clubs were geo-referenced to the local area with which they are most associated, so Manchester United’s data, for example, is for Trafford Council, Chelsea FC is represented by data from the Royal Borough of Kensington and Chelsea, and Swansea is represented by data from the local health board (although the Wales average had to be used for the alcohol variable). Liverpool and Everton have the same data as their grounds, Anfield and Goodison,are located in the same local authority.

    Life expectancies

    Apart from throwing up some unusual league places, the league table also further demonstrates the extent of the north-south divide in health in England: the top half of the table is dominated by southern clubs and the relegated trio are all from the north-west. To those working in public health, this will not be surprising as the cities of Liverpool and Manchester have some of the worst health outcomes in the country. The contrast between winners Chelsea and relegated Manchester City in terms of life expectancy is immense at seven years for men and six years for women.

    The PHLT also demonstrates the local health inequalities that exist within our towns and cities. So while Manchester United place in the top four, their “noisy neighbours” Manchester City are relegated. Life expectancy for men and women on the red side of Greater Manchester is four years higher than for those on the blue side – only a couple of miles down the road. This is probably related to the stark differences on these two sides of the same city in terms of economic deprivation with, for example, child poverty rates of 34% for Manchester City Council compared to 14% in Trafford.

    Manchester death league

    Even within local authorities there are high inequalities in life chances with, for example, a 14-year gap in male life expectancy between the most and least deprived areas of Chelsea.

    The north-south health divide, local health inequalities, and inequalities within local authorities are a serious public health concern – to the extent that they were the subject of Due North, the first Public Health England commissioned independent review in 2014. This report recommended a number of ways in which central and local government and the voluntary sector and the NHS could help reduce these health divides. The league table is another way of showing these divisions and raising awareness of the inequalities in “life and death” that exist in our country today.

    This was first published on The Conversation

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    We are currently being told by the Coalition government that we are “all in it together” and that recession, austerity and cuts to welfare and the privatisation of the NHS are the necessary medicine to revitalise our broken country. This is a dangerous, neoliberal myth.

    We are not “all in it together” and there is clear evidence that austerity is bad for health and that health inequalities are beginning to increase. Since 2007, suicide rates have increased across England – but at a greater rate in the more deprived areas. Similarly, antidepressant prescription rates have risen, again with the highest increases in poorer places. Food bank use and malnutrition rates have also increased more in the more deprived North of England. Austerity inspired cuts to welfare and local government have also impacted far more on poorer areas – as they lose around four times as much funding as the more affluent areas.  These cuts will only serve to widen health inequalities between areas and between rich and poor.

    In contrast, our research published this week has shown that in fact, it is higher welfare provision that protects health and health inequalities in times of economic downturn. We examined the effects of economic recession on health inequalities in the two historically contrasting welfare states of England (amongst the least generous in Europe) and Sweden (amongst the most generous). We used data for a 20 year period from 1991-2010. We found that the health of the least educated English women worsened during recessions, in contrast, in Sweden, the health of all women improved significantly during recession regardless of their educational status. This suggests that Sweden’s more encompassing welfare state protects the health of all during recessions. The study can be accessed here.

    This of course gives good reason to fear for the future of health inequalities in England as a result of the “Great Recession” and the unprecedented cuts to public services and the welfare safety net. We are now studying this in the hope of providing evidence to inform a future Labour government: more details.


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    Health and Social Care Community  Profiles

    map and picture

    The more widespread availability of statistical data on the Internet provides new opportunities for the voluntary sector to explore local issues related to health inequalities. In addition there is also access to local knowledge and strategic planning information, as well as academic literature related to health inequalities, which provides useful additional background information, knowledge or local based data.

    Community and voluntary sector organisations can contribute to local strategic planning around health and social care, if they understood in more detail, the needs of their communities better. Information could also be used to support the activities of local health activists, political parties all politicians, and other community or public sector health-related work.

    Often city council level analysis of needs doesn’t reach down, to the local level at which health inequalities are experienced. County council, unitary or district level strategic planning doesn’t always identify local communities detailed needs. For example, data analysis is often at district or unitary level, or examining (at best), ward level differences. Communities across Ward level boundaries or lie within the Ward areas. Issues such as physical location, the physical environment and the layout of transport links can actually create or exacerbate issues around access to services for groups of people or for specific communities. Issues like these are of real interest to local community groups, who are working within these communities in areas.

    Information could be used within the voluntary and community sectors for their own strategic planning; preparing funding bids and supporting those bids, service review and development, etc. Community groups could benefit from a needs assessment of particular groups or communities locally, and comparisons with other groups or areas- to inform their service delivery.

    However, getting access to the right information – and putting it together in the right way can be a challenging, for those who have more experience of service delivery and voluntary sector work, than of research. The Internet websites providing official statistics for example, all work in a slightly different way – and provide data at different levels in different formats.

    Increasingly, statistical data websites offer more sophisticated tools to enable more detailed analysis at a lower level – in fact, there are websites that allow bespoke data analysis to fit the needs of the organisation. This can be to level of community, rather than at the level of ‘administrative areas’. Communities stretch across Ward boundaries, and share common problems accessing services, and so on. These can be ‘hidden needs’ in strategic planning (that doesn’t penetrate down to that level, or embrace the’ natural form’ of different communities within larger areas). One example is the Neighbourhood Statistics website, where it’s possible to create lower-level census output areas into bespoke community or geographical areas.

    ONS screen shot

    The key to getting information that’s relevant, and can inform the organisation’s work – is forward planning and thinking. The organisations remit, and the aims of the particular research project need to be spelt out carefully – and possibly negotiated with stakeholders before any actual data collection begins.

    The process of deciding what the research aims are, and linking this to the organisational needs is the most crucial part of the planning required to make best use of available data.  This process can be broken down into ten stages, which are outlined in this training video below. It uses using the example of a profile for a community group’s application for funding for a ‘neighbourhood care service’ in a deprived area. It explains in detail how to think about planning and doing a community profile. The focus of this example is looking at ‘care needs and capabilities’ within this deprived area, related to the potential for a neighbourhood care service.

    Kate Bloor – KNVresearch January 2014


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    Labour’s New Approach to Public Health in the 21st Century


    When the NHS was created in 1948, life expectancy in England was 66 years for men and 70 years for women. Today it is 79 years for men and 83 years for women and set to keep on getting longer as this century progresses.

    This is welcome but poses new challenges for our NHS and more importantly, for us all as individuals, parents and families. If our bodies are to be on the road for longer, all children will need the healthiest possible start in life and the earliest possible intervention when needs arise. And, as we grow older, we will all need to take better care of ourselves, if we are to get the most out of life in our later years. It is still not widely understood that lifestyle has an impact not only on the chances of developing diseases like cancer and heart disease, but also affects the chances of  developing diseases like dementia too.

    The truth is that individuals and communities will need to be helped to take more responsibility for their health. Because, if we don’t make changes, the NHS simply won’t be sustainable in a century of rising demand for healthcare. So that’s why the nature of the public health challenge has changed. If the 20th century challenge was all about adding years to life, then the 21st must also be about adding life to years.

    But here’s the rub: the very nature of 21st century living works against it. Changes to diet and lifestyle mean it is all too easy to lead a less healthy life than in times gone by, and we all risk taking on more sugar, fat and salt than is good for us and failing to move about enough to burn it off. Our complex and fast-moving modern world is exposing children to ever-more sophisticated commercial pressures. We are all absorbing higher levels of stress and insecurity which can erode mental health and wellbeing and lead to poor diet and addiction. For too many people this is the new reality of modern living in the 21st century. Helping people deal with it will require a new approach to public health. If it was ever true that healthier nations can be built through Government action alone, then it’s certainly not true now. Instead, we need to build a different culture where we empower individuals to take on more responsibility for their own health and help communities look after each other.

    This is one of the main conclusions of Labour’s root-and-branch review of public health policy.

    In Government, Labour took a number of bold steps to improve the nation’s health. For example, teenage pregnancy rates fell by over a quarter and the proportion of non-smokers in the population increased significantly. The ban on smoking in enclosed public places is an example of how big social change to improve health can be achieved with broad public support.

    But, to avoid accusations of a ‘nanny state’ approach we need to set out clearly what we see as the proper limits to government action. If policy makers fail to address the ‘nanny-state’ claim, it could in the end undermine public support for making progress on public health. A negative tone, perceived as telling people what to do, can turn people off. On the other hand, there is a danger in over-reacting to the ‘nanny-state’ charge and failing to take the necessary action to protect people’s health.

    The current Government, fearful of it, and unable to stand up to vested interests, has relied too heavily on a voluntary approach with industry. It has not worked. The 2010-2015 Parliament has seen a real loss of momentum on public health policy, with the Government failing to deliver promised measures, such as on tobacco packaging. It has been left it to Labour, from the Opposition benches, to lead the public health debate with the move to ban smoking in cars with children and proxy purchasing of cigarettes.

    The time has come to find a better response to concerns about the ‘nanny state’ and a new point of balance in the public health debate. We must be clearer about where the state has a particular duty to intervene and where it should instead focus on empowering people to make informed choices.

    To help this, Labour proposes two new guiding principles for public health policy:

    • For children, we will take decisive action to give each child a healthier start in life.
    • For adults, we will place a new emphasis on empowerment to make healthier choices.

    In this complex modern world, there is much more that we can, and should, be doing to protect children from the pressures and risks they face. Adults must be free to make their own choices but there is more we can do to help people navigate the system and take more responsibility for their own health.

    Labour’s new approach to public health can be illustrated in food policy. We propose to regulate for a maximum level of fat, salt and sugar in food marketed substantially to children while to support the population as a whole, Labour will pursue improvements to food labelling to help people better understand what they are eating, including working at EU level to introduce mandatory traffic light labelling of packaged food.

    While it is first and foremost the responsibility of parents to secure the health of their children, the justification for firmer Government action in respect of children comes from the fact that other people frequently make choices on their behalf: what they eat or drink; the environment in which they are placed; the structure of their day. Because of that, government has a clear responsibility to minimise the harm that poor choices can do to a child’s health. There is far more we can, and should, be doing to protect children from the harm caused by smoke, sugar, alcohol and inactivity – and give every child a better start in life – and we will not be deflected from doing it.

    But, beyond that, we will develop a different approach to promoting the health of the rest of the population. We will empower people with better information and support to make their own choices, rather than the finger-wagging ‘don’t do this, don’t do that’ approach that can make people switch off.

    Emblematic of this new thinking about an empowering approach to heath is our plan to place the promotion of physical activity at the centre of public health policy. Building a more active nation will be our pre-eminent public health objective. Physical activity offers the simplest, and cheapest, route to good health. It is a positive call to action and, for many, the easiest lifestyle change to make. But it also has the virtue of being a catalytic change, prompting positive changes in diet and on levels of smoking and drinking. Rather than set a Government target, we will instead develop a new national ambition on physical activity. We will encourage companies, councils, charities and others to sign up too and join a new national campaign to build a more active nation.

    Asking individuals and communities to do more to promote health is a recognition that, going forward, action on public health is essential not only to improve health and wellbeing but to ensure the NHS remains sustainable for the long term.

    We need to help people look after each other. The plan we set out here for all young people, by the time they have left school, to have had access to emergency first aid training along with a new plan to locate defibrillators in major public places is just one example of how we will build that community resilience.

    Though Labour’s new approach to public health reflects changing times, our historic mission remains the same: to break the link between health and wealth and tackle health inequalities, so that no-one’s health is disadvantaged by where they live or what they earn. To be successful, our new approach will need to be supported by the ‘health in all policies’ approach, as advocated by Professor Sir Michael Marmot.

    Labour believes that the NHS needs to break out of its 20th Century medical model and embrace a new whole-person, social model of support that starts with prevention. By asking Health & Well-being Boards to lead local commissioning for the increasing number of people with complex and multiple needs, and by bringing together services to work around the individual, we will finally be able to link health policy at a local level with all of the other local policies that have a bearing on health – most notably, housing, planning, education, employment, skills and leisure – and, in so doing, build more resilient individuals and communities. Bringing together services, in this way, will also help create the right conditions and incentives for services to intervene earlier to stop problems before they arise or become worse. 21st Century living, and the scale of the challenges ahead of us, demand new thinking, new ambitions and new leadership on public health. Labour has traditionally led the way on public health policy and is ready to do so again.

    The scale of the challenge

    When the NHS was established, many of the biggest health problems in the UK were curable illnesses like infectious diseases and accidental injuries. Over half a century later the picture is very different. Overall, health is improving and our life expectancy has increased. We have controlled or conquered many of the infectious diseases such as polio which blighted previous generations. Many thousands more people are now living into their 80s and 90s, and beyond, as life expectancy has improved.

    Obesity, tobacco and alcohol are contributing to the development of long term conditions such as diabetes that require lifelong treatment. Opportunities to be regularly physically active are declining in our daily lives, some of us are regularly eating and drinking more than is healthy, and the growing stresses and insecurity of modern life are adding additional pressures to our mental health. This new reality requires new thinking on public health. We have added more years to life, now we also have to add more life to those years. The ageing society should be a cause for celebration not a cause of fear.

    Changing this means embracing new ways of tackling entrenched challenges. Right now, the 21st century is asking questions of our 20th century health and care system that it is increasingly unable to answer. To plan our future health services and ensure the best use of our resources, we must understand the true picture of the public’s health.


    Our lives have changed significantly over the years. The quality and range of food available has improved, but so too has the formulation of much of the food and drink that children consume. Nearly two-thirds of adults and a third of children in England are classed as being overweight or obese. More people, children as well, are getting Type Two diabetes and other obesity-related conditions. It is predicted this will affect the life expectancy of millions and will also hit the NHS.

    Obesity related illness such as heart attacks, strokes and diabetes are already costing our NHS over £5 billion a year and this is expected to rise to more than £8 billion by 2025. The cost to wider society is of course much higher and is estimated to reach £37 billion by 2025.

    The nation’s diet today is very different to our diet when the NHS was created. Modern food manufacturing and marketing techniques make it harder for parents to make healthy choices for their children. The rise of food processing has meant that, unwittingly, we are eating more fat, salt and sugar than we realise. For example, parents used to be able to monitor the amount of sugar their children were adding to cereal from a bowl on the breakfast table; now, large amounts are often added at the point of manufacture, before it reaches our bowls. A Which? report in early 2012 found that sugar levels in 32 out of the 50 breakfast cereals they examined were extremely high and they were particularly concerned about the sugar levels in cereals that were marketed to children. It is notable that in some cases there is a marked variation in the amount of sugar in the same cereals as marketed in different countries. In the UK, it is recommended that no more that 10% of our food energy should come from sugar. The World Health Organization suggests that we should in fact be aiming to go much further and get the level of sugar in our diet down to 5%. But currently, in children aged 4 to 10 years, it is 15% and in those aged 11 to 18 years it is 15%. Teenagers’ intakes are the highest of all groups – they consume 50% more sugar on average than is currently recommended.

    The UK is the biggest market for salty snacks in Europe and the demand is mostly amongst the young. The National Diet and Nutrition Survey found that our salt intake was higher than the recommended levels for all groups of children and adults. Our average intake of saturated fat exceeds the 11% recommendation in all age groups.

    Yet change towards a healthier diet and all of us living more active lives is painfully slow. The voluntary approach with industry – through the Government’s Responsibility Deal – has failed to deliver the goods.

    Physical inactivity

    Just a few generations ago, physical activity was an integral part of daily life. Modern life makes it much harder to be physically active and many of our children and young people are not getting sufficient activity to learn good lifelong habits and stay strong, fit, healthy and happy. Advances in technology, community safety concerns and limited access to green spaces are just a few of the reasons why.

    Getting people walking and cycling from a young age is crucial to building lifelong well-being and resilience, improving the environment and cutting transport congestion. Yet only around half of children are walking or cycling to school. In England only 2% of primary school children cycle to school compared with almost 50% in the Netherlands.

    It is becoming clear that sedentary behaviour (sitting or lying down for long periods while doing things such as working at a computer or watching TV) can cause health problems. Insufficient levels of physical activity are estimated to cost over £7.5 billion nationally, £1.06 billion in the NHS, £5.5 billion in lost productivity and £1 billion in premature mortality in the working age population in England.

    Labour had a strong record in promoting physical activity – and particularly promoting sport for children and young people. In 2003/4, just 44% of children undertook at least two hours of PE in school, but by the end of our time in government this had been raised to 84 per cent. This Government has scrapped School Sports Partnerships, axed Labour’s school sport targets and a recent Youth Sport Trust survey found an alarming drop in the amount of PE offered to children in England. The Tory-led Government abandoned the legacy on physical activity that Labour left, failed to show leadership on active travel, and missed the opportunity to build on the once-in-a-lifetime Olympic moment after the 2012 games in London. At the same time as the country was engaging more with sport, the Government was dropping the free swimming programme, axing Cycling England and stopping the school travel survey.

    Smoking and tobacco

    Smoking is the largest cause of preventable illness and death. There are about 10 million adults who smoke in Britain, around 20% of the population. Every year smoking causes around 100,000 deaths and it is also a major driver of health inequalities – smoking rates are markedly higher among low income groups. Yet there are still more than 200,000 children under the age of 16 who take up smoking every year, according to Cancer Research UK. That means around 600 children are lighting up for the first time every day.

    Under the previous Labour Government, the proportion of adult smokers fell from 28% to 20% between 1998 and 2010, due to a series of national initiatives, including the ban on smoking in enclosed public places and the raising of the legal age for buying tobacco from 16 to 18. Other significant steps forward included expanding NHS Stop Smoking Services, supporting hundreds of thousands of smokers to quit. Yet the Tory-led Government has failed to build on this work. In the face of prevarication from the Government, it was left to Labour, from the Opposition benches, to push forward the legislation to enable the introduction of standardised packaging of cigarettes and a ban on smoking in cars with children.

    But that was over two years ago and the regulations on standardised packaging have not yet appeared, despite parliament voting overwhelmingly in favour of it and numerous evidence reviews showing that standardised packaging prevents young people and children from taking up smoking. The failure of ministers to act is not because of a lack of time or a lack of evidence. It is because of a lack of political resolve to stand up to big tobacco firms and their lobbyists. The fact is that the Government has come under intense lobbying from the big tobacco companies and vested interests, attempting to persuade ministers to sit on their hands.

    Mental health

    One in four of us will have a mental health condition at some point in our lives and one in twelve of us will experience depression. The insecurity of modern life – precarious employment, people working and living away from their families and the pressures of social networking and the 24-hour society – can erode our sense of mental wellbeing.

    For the first time, stress is the most common cause of long-term sickness absence for both manual and non-manual workers. The number of prescriptions for anti-depressant drugs has increased by around 93% over the last decade from over 27 million in 2003 to over 53 million in 2013. Undiagnosed or untreated mental illness can have a devastating impact on  individuals and their families. It has real consequences for our society and our economy. The annual cost in England is estimated at £105 billion. Yet, the Government is failing to fulfil their promise of delivering parity of esteem between physical and mental health. Pressures on mental health services are increasing to intolerable levels, with vulnerable people forced to travel hundreds of miles for a bed and in some cases they are not receiving the treatment they need at all.

    Sexual health

    The rates of some sexually transmitted infections are steadily increasing. Since 2010 we have seen upward trends in syphilis, gonorrhoea and genital herpes. In 2012 there were nearly half a million new cases of sexually transmitted diseases, with chlamydia infection making up nearly half of those cases. Rates of infectious syphilis are at their highest since the 1950s and in England in 2011, one person was diagnosed with HIV every 90 minutes. Last year a Public Health England report found the number of people living with HIV in the UK has exceeded 100,000 for the first time. Despite these increases, sexual health services have been fragmented as a result of the reforms to the NHS, statutory Sex and Relationships Education has not been included in the National Curriculum, and youth services – a crucial part of reaching young people most at risk outside school and college – have been drastically cut.

    The progress that was made under the previous Labour Government in reducing teenage pregnancies is at risk of being undermined. It has been estimated that if the current squeeze on services continues and strategic work continues to be dismantled, the additional cost to the NHS plus wider public sector costs could total between £8.3 billion and £10 billion.


    The UK rate of alcohol dependency amongst men and women is higher than all Western European countries other than Norway. Excessive drinking is associated with a wide range of chronic diseases including liver disease, cardiovascular disease and cancer, as well as with crime and disorder.

    In 2012, there were 8,367 alcohol related deaths in the UK. Deaths from liver disease have reached record levels – a 20% rise in a decade. In people under 30, liver disease death rates have increased by 112% over the last ten years. Other evidence highlights the damaging effects of alcohol including the number of A&E attendances and the levels of domestic violence and disorder on our streets. The rise is excessive drinking has been fuelled by the increasing availability of low-cost, high-strength alcohol. Cheap, high-strength alcohol is now a permanent feature on the supermarket shelves including an endless wave of special offers and promotions, and such marketing has been shown to be particularly attractive to harmful and dependent drinkers, binge drinkers and young drinkers.

    Our society’s relationship with alcohol also impacts on our children. It is estimated that 2.6 million children in the UK are living with parents who are drinking hazardously. In 2012/13 6,500 under 18s were hospitalised because of alcohol, including 283 under 11s. Indeed almost half of school students say that they have drunk alcohol at least once.

    Tackling health inequalities

    Improving public health will be an essential part of ensuring the NHS remains sustainable for the next generation. And it is the best way to avoid a  frightening vision of a future where the Chief Medical Officer’s warning that today’s children may live for fewer years than previous generations is realised. Indeed, there is already emerging evidence that life expectancy amongst the elderly is falling in some parts of the country. Despite a 27 per cent reduction in the infant mortality rate under the previous Government, the UK is still behind its European neighbours in preventing deaths among children, with the causes affecting the more disadvantaged communities in our society.

    The substantial gap between the health of the worst-off and the most prosperous in our society continues to be persist. The stark truth is that people living in the poorest neighbourhoods will on average die 7 years earlier than people living in the richest neighbourhoods. Where you live in modern Britain, what you earn and how long you stay in education, may still impact on your health.

    Left unchecked, these public health challenges will not only ruin the lives of individuals, they will also impose substantial costs on the health service and our wider economy. Our NHS will face a large funding gap by 2020 unless action is taken. Demand will rise faster if we as a society do not do all we can to prevent avoidable illnesses. The long-term capacity of the NHS to treat everyone who needs it will be at risk without a strong focus on wellness and prevention as well as cure.

    Progress on tobacco and teenage pregnancy between 1997 and 2010

    The proportion of adult non-smokers in the population rose from 72% to 80%  between 1998 and 2010. This was due to a series of national initiatives implemented by the Labour Government, of which the most striking was the restriction on environmental tobacco smoke in public places. Other significant steps forward were tough legislation on vending machines and tobacco advertising at point of sale. The creation of several Regional Tobacco Control Offices and the extensive network of NHS Stop Smoking Services were further examples of Labour’s commitment to saving a hundred thousand lives currently being lost to tobacco every year.

    The rate of teenage pregnancy fell by 27% during the Labour Government and the downward trend achieved by better sexual health services for young people and dedicated funding for long-acting contraceptives has continued. The introduction of HPV immunisation for teenagers under Labour is a good example of a successfully developed and implemented public health programme.

    The Government’s approach is not working

    The sheer scale of the public health challenge we are facing demands strong leadership and bold ambition. The Government has failed to show either and has lost its way on public health.

    When the Coalition Government came to power in 2010, the health of the nation had showed significant improvement. Infant mortality was at an all-time low, cancer mortality had fallen and teenage pregnancy had dropped by nearly a quarter. But the Government has failed to build on this legacy. Their decision to abolish the Cabinet Sub-Committee on Public Health after only two years is indicative of the failure of ministers to make public health a priority across all government departments. Much of the progress in public health made under the previous Labour Government has stalled, if not started to reverse.

    The defining approach to public health from this Government is a heavy reliance on voluntary action with industry. The decision to rely largely on the ‘Responsibility Deal’, a programme encouraging business to take action voluntarily to improve public health, has raised the concern that the Government has become too close to commercial interests to take the bold action on public health that is required. The scale of the challenge we are facing is too great to rely solely on a non-binding and piecemeal deal with a select group of companies. Some of the major supermarket chains, big drinks producers and high street food outlets have signed up, but other organisations have walked away from the scheme, including Cancer Research UK and the Faculty of Public Health. Many initiatives such as cutting salt and removing harmful trans-fats were already under way before the voluntary scheme was launched, while newer ones such as the drive to increase vegetable and fruit consumption were too “vague” to be meaningful. The monitoring and evaluation framework is not sufficiently robust or independent. The Government has set no timetable for reviewing progress and has failed to outline the action it will take if results are not achieved. In the latest annual report, nearly a third of the retailers and suppliers signed up to the Deal’s various pledges failed to hit the targets they set themselves.

    Industry is disappointed too.

    While some of the companies signed up to the programme have made significant effort and progress, and the steps they have taken are recognised and very welcome, by itself this is not enough. And those companies who try to do the right thing are undermined by competitors who refuse to join.  This leaves those who want to make changes at a competitive disadvantage. Some companies have taken commercial risks to bring forward change, whilst others have simply refused to sign up and have continued undisturbed. It is not surprising that many of those that had signed up, drop out. For change to work in a market context, all players need to be following the same rules. Key players in the sector are calling for transparency and clarity along with a level playing field.

    Alongside the absence of strong leadership on public health policy, the Tory led Government has disrupted the public health system as part of the reorganisation they have imposed on the NHS. Labour welcomes the shift of much of public health delivery to local authorities. It is right that the power to make decisions about a community’s health and wellbeing sits with the community itself and that is where it will stay under the next Labour Government. However, this transfer has created problems in practice. Some places have failed to appoint a Director of Public Health on a substantive basis and the Government has failed to ensure that Public Health budgets in some areas have been spent effectively.

    Improving health and well-being needs to be at the heart of everything a 21st century local authority delivers, rather than just an add-on. This approach links closely to our proposals for the full integration of physical and mental health and social care. A service that cares for the whole person needs to include preventative public health measures. This Government has failed to provide the answers on public health that we need. Too often they are unwilling to stand up to vested interests or are ideologically opposed to intervening in markets. We need a new approach.

    Labour’s new approach

    Labour’s new, two-part approach to public health is borne out the desire to avoid a ‘nanny-state’ approach on the one hand, whilst recognising the failure of the Government’s heavy reliance on a purely voluntary approach with industry on the other. The point of balance lies between the two:

    • Decisive government action to protect children;
    • Empowering people to lead healthier lives whilst respecting their right to make their own choices.

    Helping parents and protecting children

    If we want to make Britain a more equal society, where children have a better chance in life, we must look more closely at the health of our young people. Children’s early experiences are central to shaping their long-term health and well-being, and reducing inequalities in health over the life course. But the reality is that we are not doing anything like enough as a society to give all children the healthiest possible start in life.

    We are clear that, when it comes to the protection of children, more decisive action by government is needed. The justification for firmer government action arises from the fact that children do not make their own choices but have choices made for them. The Government has an obligation to protect children from poor choices that may be harmful to their long-term health. An example of Labour’s more decisive approach in respect of protecting children was the decision to seek, and secure, Parliamentary approval for protecting children from tobacco smoke in cars. It is developed further in new policies in this document on physical activity, food, smoking and alcohol. But the Government should also do more to support parents trying to make the right decisions for their children. Modern marketing and advertising techniques, along with commercial pressures, can make this difficult.

    Government has a crucial role to play in standing up to vested interests and empowering parents to make informed choices. Indeed, this is action the overwhelming majority of parents want: recent polling has shown three-quarters of parents think the Government should more strictly regulate the way junk food is advertised to children.

    A more positive enabling approach

    The last Labour Government had a good record of achievement in many important areas of public health, but there were areas where, when we left government, we knew further action was needed. We know we can’t tackle some of our most entrenched public health challenges from within the health system alone. We also know that legislation is not the answer to everything. Good health is not created by the Department of Health, nor solely by the actions of the NHS. It is the product of many separate policies and activities, not just in government departments but also in communities, schools, workplaces and homes across the country.

    Whilst we are clear that the Government has a responsibility to protect and safeguard children and has an important role to play in tackling health inequalities, we are not in the business of telling people how to live their lives.  The evidence shows it simply doesn’t work. Public health is about a partnership between businesses, governments, the voluntary sector and the citizen. It is not something done to people by experts.

    Instead, we want government to be on people’s side, supporting them in making healthy choices and improving their health and that of their family. We propose new national ambitions – positive, shared aspirations that will help us all play our part to become a healthier, happier nation. International comparisons show that smoking can be reduced further, obesity and associated illnesses reduced and physical activity improved. We are setting out ambitions for our country that people can share, companies and organisations can partner in, and that are achievable.

    A focus on physical activity as the positive catalyst for change

    We will focus on positive catalysts for change and physical activity is the golden thread running throughout our entire public health policy  programme. Promoting physical activity is a single, simple, positive goal for the whole country to get behind: a goal that has the potential to shift our national culture. It is not about finger-wagging; it is about promoting a positive activity that people can feel good about. Moving from inactivity to activity is often the easiest positive lifestyle change to make, by making small changes to build physical activity into our daily routines, we can make big differences to our health.

    Moving from inactivity to activity is a catalytic change. Once achieved, people begin to feel better about themselves and more in control – and then make better choices on smoking, drinking and diet. Getting active not only brings physiological benefits – it can improve mental health too. Active young people are more alert, and less likely to suffer from stress or depression. For young people, physical activity is fundamental to their happiness and development. The evidence also suggests that children who are fit have higher academic attainment. Turning the tide of inactivity is not just one of the easiest ways for an individual to achieve healthy living, it is the cheapest route to good health and well-being for the whole population and the most cost-effective way of making our public services sustainable. It is also why we support public health being an important role for local government which has the overview of its community and the policy levers to make change happen.

    Our Guiding Principles

    In 2008, Labour commissioned the Marmot Review of Health Inequalities. The final report, Fair society, Healthy lives was published in February 2010 and recommended a change in approach. The Labour Government accepted those recommendations but their implementation was interrupted by the 2010 general election. The Marmot Review identified a series of principles that reached across a wide range of Government responsibilities that will guide the next Labour Government including:

    Early intervention

    Labour believes that that giving every child the best start in life is of crucial important in setting healthy foundations for the future. Supporting children and families in the very first months and years of life is especially important given this is a time of rapid development with a huge impact on later outcomes.
    The Marmot Review identified a number of key policy objectives that were important to achieving that healthy start.
    The priorities identified were:
    1. Reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills.
    2. Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient.
    3. Build the resilience and well-being of young children across the social gradient.
    We are committed to acting across the broad sweep of public policy and working towards making these objectives a reality.

    Health in All Policies

    We will adopt the internationally accepted ‘Health in All Policies’ approach – putting health concerns at the centre of our programme for government. Improving our health is not in the gift any one department, organisation or agency, it is the product of many separate policies and activities not just from government but in communities, schools, workplaces, businesses and homes across the country. Successful policy must build a systematic approach that mobilises all of the relevant government departments, local authorities and community and voluntary groups to contribute to a broadly based approach to improving the health of all of our nation. This is why Labour will re-establish the Cabinet Sub-Committee on Public Health.

    Proportionate Universalism

    Our clear ambition is to reduce health inequalities. However focusing solely on the most disadvantaged will not make a big enough difference. We need to take universal action on the major problems affecting our health, but with a focus and intensity that is proportionate to the level of disadvantage in different communities and groups.

    Our programme for action

    Physical activity

    Our ambition: We should aspire to helping everyone in this country be more active. We will develop new measures for recommended levels of physical activity that can be easily understood by everyone, and are consistent across government, including a basic minimum that everyone who can should try to do, and also a recommended level that we should aspire to get at least 50% of people achieving by 2025 as part of our new national ambition.

    This will be our pre-eminent public health goal. It will be supported by a new national ’50 by 25′ campaign that we will ask council, companies, charities and voluntary organisations to join. By signing up, organisations will be agreeing to take steps to get 50% of local people, employees or their members physically active.

    Protecting children

    • We will reinstate the goal of all children doing a minimum of two hours PE a week as part of the curriculum and support the delivery of high quality sport, PE and physical activity.
    • Labour will deliver a primary school childcare guarantee, offering parents wrap-around childcare between the hours of 8am and 6pm.
      This will provide more opportunities for children to participate in up to three further hours of sport and physical activity every day.

    Empowering all

    • We will give local authorities an expanded remit to support physical activity in communities. We will look at how we can better support local communities so that they have the opportunity to use sporting facilities in schools outside school hours, including at weekends, and outside term time.
    • We will work with local authorities, learning form the measures introduced by Labour in Wales, to steadily improve the walking and cycling environment in all communities.
    • We are committed to restoring national standards to cut deaths and serious injuries on our roads and taking steps to make HGVs safer.
    • Labour wants every child to have the opportunity to learn to ride a bike.We want to see cycling education and training continue in the next parliament.
    • A national programme will be put in place to support social prescribing of physical activity, by health and social care professionals, for people who would benefit.


    At a time when families are facing a cost-of-living crisis, Labour does not believe recent calls to impose new taxes on foods are the right approach for encouraging healthier diets. That is why, instead of pursuing proposals such as a ‘fat tax’ or a ‘sugar tax’, Labour will instead take a new approach. Faced with high levels of childhood obesity and the inadequacy of relying solely on industry to make the changes that are needed, Labour will set maximum permitted levels of sugar, salt and fat in foods marketed substantially to children.

    Our ambition: To help give all children a good start in life by tackling the barriers to a healthy diet. We will achieve a sustained downward trend in levels of childhood and adult obesity; reverse the growth in cases of malnutrition; and increase the proportion of children eating healthily.

    Protecting children

    • Labour will set limits on the amount of sugar, fat and salt in food marketed substantially to children focusing on major product groups – for example cereals, crisps and soft drinks.
    • Whilst restrictions on TV advertising for unhealthy products have reduced the number of advertisements children see during children’s programming, it is still the case that many children are exposed to adverts for foods high in fat, sugar and salt that the current restrictions were designed to protect them from – for example during some family TV shows on Saturday evenings. To better protect children from TV advertising of products high in sugar, salt and fat, we will ask the Committee on Advertising Practice (CAP) and the Advertising Standards Agency (ASA) to report on how this can be more effectively done, including considering lowering the proportion of children in the audience required for a programme to be considered ‘of particular appeal to children’. If progress cannot be achieved through this route, we will regulate to protect children, with options including a time watershed for advertising of products high in sugar, fat and/or salt (HFSS). We remain committed to basing our actions on the evidence and consulting fully with all stakeholders, including the advertising and  food industries and public health experts, in the implementation of this.
    • We will also ask the CAP and the ASA to report on how children can be better protected from the advertising of products high in sugar, salt and fat in non-broadcast media, such as ‘advergames’, including considering the case for applying to non-broadcast media a differentiation between HFSS and non-HFSS foods similar to that which exists in the broadcast code.

    Empowering all

    • We do not believe that EU regulations on labelling go far enough in ensuring that all consumers have the information they need to make healthy choices. We will pursue improvements to the regulations at an EU level, including working to introduce traffic light labelling of packaged food, aiming to achieve a standardised and easily understood system of food labelling in respect of its nutritional content
    • Labour will give local authorities new powers so that local communities can shape their high streets and limit the future number of fast food outlets locally. Currently these premises can often be opened without applying for planning permission, but this change will allow local communities to require them to apply for planning permission. This will give local communities real power to stop the proliferation, clustering and over-concentration of fast food outlets.
      These steps forward on food will be part of our broader agenda on food – achieved by reinstating the Food 2030 strategy – of pursuing an integrated approach, supported by dialogue with industry, experts and campaigners. This is set out in more detail below.

    Food 2030

    Food policy needs an integrated approach that is why the last Labour Government developed the Food 2030 strategy. This was complemented by a Cabinet SubCommittee to coordinate policy across Whitehall and chaired by the Secretary of State for Environment, Food and Rural Affairs. The committee was supported in its work by a council of food policy advisors to create a forum for ongoing dialogue with industry figures, academic experts and campaigners.
    Food 2030 has been quietly shelved by the current Tory-led Government and as a result policy has been characterised by chaos, fragmentation and poor outcomes for consumers. Since 2010 public faith in our food system has been undermined by:

    • The horsemeat scandal and high levels of campylobacter in supermarket poultry products,
    • A failure to address rising obesity levels which is placing unsustainable pressure on the NHS,
    • Rising levels of malnutrition and record numbers of people relying on emergency food aid.

    The Labour Party will reinstate the Food 2030 strategy and associated committees to ensure that our food system works for ordinary people. The Cabinet Sub-Committee and council of food policy advisors will consider a range of issues in the delivery of the Food 2030 strategy. These will include:

    • Reducing levels of obesity with a particular focus on children. This will include dialogue with the Department of Health, representatives from the food industry, academic experts and campaigners on developing the best approaches to implementing measures to reduce levels of sugar, salt and fat in products marketed substantially at children. We will examine the best approaches to limiting the marketing of products with high fat, salt or sugar content reaching children via television and non-broadcast media channels.
    • Ensuring that the food industry puts the consumer first by strengthening the Food Standards Agency (FSA). Labour will reverse the machinery of Government changes that weakened the FSA to ensure that the agency has the capacity to stop food fraud, improve safety and tackle unhealthy practices.
    • Reducing dependency on food banks. This will be supported by an ongoing dialogue with the Department for Work and Pensions, church groups and other emergency food providers to monitor the use of food banks.
    • Raising earnings and improving career opportunities in the food and farming sector where low pay is all-too prevalent with an employment culture often characterised by agency-work, short-term and zero-hours contracts. The Government’s abolition of the Agricultural Wages Board exacerbated this
      situation by removing protections for rural and agricultural workers. Labour will work with the food industry – one of the most important employers in rural areas – to raise skills and wages, and help small firms and food businesses access the investment they need to expand and train. We have set out plans to raise the minimum wage to £8 an hour and empower the Low Pay Commission to work to with low paying sectors to raise wages.


    Two thirds of adult smokers took up smoking as children. So alongside helping people to quit smoking, supporting those who have quit not to relapse and reducing exposure to second hand smoke, we want to focus on protecting children and helping them not take up smoking in the first place.

    Our ambition: To reduce smoking prevalence to 10 per cent by 2025. Over the longer-term we will have as a goal that children born in 2015 will become the first “smoke-free generation” in hundreds of years.

    Protecting children

    • Standardised packaging of tobacco products will be introduced immediately to halt the industry’s increasingly sophisticated methods of recruiting new, young smokers.
    • Schools will be able to use the curriculum freedoms open to them to provide opportunities for public health programmes, such as tobacco education via peer-based learning initiatives.

    Empowering all

    • We will continue to monitor the emerging evidence on the appropriate use of devices such as e-cigarettes in smoking cessation and take action if required.
    • A levy on tobacco companies will be used to ensure they make a greater contribution to the cost of tackling tobacco-related harm.


    We will focus on tackling the public health problems associated with excessive drinking and particularly drinking by children. We will do this by targeting the high-strength, low-cost products that are affordable to children, fuel binge drinking and do most harm to health, but this will not affect the vast majority of people. As with our proposals on food, we will have a particular focus on those products that harm young people.

    Our ambition on alcohol: We want to support people to make healthy choices on drinking, helping to reduce the proportion of the population who regularly drink excessively, and we will also tackle the problems of underage drinking, to cut significantly the proportion of children who drink.

    Protecting children

    • Labour will crack down on the high-strength, low-cost alcohol products that fuel binge drinking and do most harm to health, such as ultra-lowpriced 7.5% white cider sold in large plastic bottles, and we are considering the following options for action to achieve this:
      (i) Prohibiting or discouraging the sale of cider in three-litre bottles. This could be achieved either by regulating the permissible size of the containers in which high-strength cider is sold, for example, prohibiting the sale of cider in bottles of more than one litre in size, or by taxing larger volume cider containers more heavily.
      (ii) Creating a new, higher duty band specifically for high-strength ciders. This would have the effect of increasing the price of high-strength, ultra-low-priced ciders without affecting mainstream ciders, in the process helping shift consumption to lower strength products.
      (iii) Whether there is a case for increasing above 35 per cent the minimum apple juice content that cider is required to contain. White ciders tend to have a low juice content which is in part what allows the price to be so low. This measure would alter the definition of cider for duty purposes requiring the producers of white cider to either pay higher duty rates or change the content of the drink.
    • We will review the promotion of alcohol, particularly in relation to children. This will include working with sport governing bodies to look at the impact of sport sponsorship.

    Empowering all

    We support the need for improved alcohol labelling so that all alcoholic beverages include the clear and visible information people need to make informed choices about what they drink (including alcohol and calorific content, and recommended daily guidelines), and we will pursue this at an EU level.

    • We will make it a mandatory requirement for all alcoholic beverages sold in UK to carry a visible warning about the risk of drinking alcohol during pregnancy.
    • We will make public health a licensing objective and we would like to include the Director of Public Health as a key consultee in the creation of a licensing statement.
    • We will ensure public health is engrained throughout the licensing system so that measures promoting public health (which could range from measures such as plastic glasses and bottles to a ban on superstrength beer and cider) are included in the licensing statement.

    Community resilience

    As well as are supporting personal responsibility, there is much more that we can do to help communities look after each other.

    One area where we can make an immediate difference is on the chances of surviving sudden cardiac arrest. Many countries are moving to increase the availability of Automated External Defibrillators (AEDs) in major public places and buildings and we should do the same. And we need to train as many people as we can – particularly young people – in the skills needed to step in and help in an emergency.

    So Labour will introduce a new ‘heart-safe’ programme:

    • Working with the third sector we will support schools and young people so that by the time every child leaves school they will have had access to emergency first aid training for Cardiopulmonary Resuscitation (CPR) and the use of defibrillators.
    • To improve the chances of surviving sudden cardiac arrest, we will work to locate AEDs in major public venues – such as shopping centres, railway stations, airports and sports stadia – and support local fundraising efforts to provide them to schools and sports clubs. In government, we will set out a strategy to drive this forward.
    • We will create a National Open Register of AEDs – available via digital apps – to give people instant information on where to locate the nearest one in an emergency situation.
    • We will ask the National Screening Committee to consider a new national screening programme for young people considered at highest risk of sudden cardiac arrest.

    Cold Homes

    Fuel poverty is a long-standing health issue: the impact of cold housing on health and the stresses brought on by living in fuel poverty have been recognised for decades by researchers, medical professionals and policy makers alike. Countries which have more energy efficient housing often have lower Excess Winter Deaths (EWDs). Children living in cold homes are more than twice as likely to suffer from a variety of respiratory problems than children living in warm homes. Mental health is negatively affected by fuel poverty and cold housing for any age group.

    Despite the progress made under the previous Labour Government, in particular through the Decent Homes programme for social housing, which resulted in the installation of over 1 million new central heating systems and the re-wiring of 740,000 homes, and Warm Front, which helped over 2 million households improve their energy efficiency and insulation, Britain has among the least energy efficient housing stock anywhere in Europe. Poor energy efficiency is the single biggest reason why so many households are in fuel poverty.

    It is clear that the policies of the current Government do not meet the scale of this challenge. The Energy Company Obligation has resulted in a significant fall in the installation of energy efficiency improvements and will leave nine out of ten fuel poor households in fuel poverty.

    Labour proposes a fundamental overhaul of the country’s approach to energy efficiency. Learning the lessons of previous energy efficiency programmes, we propose an ambitious, long-term programme to end the scandal of cold homes and lift and protect people from fuel poverty, support millions of households and businesses to improve their energy efficiency and establish energy efficiency as a national infrastructure priority. We intend to take six key actions to achieve this:

    • Free energy efficient improvements for 200,000 households in or at risk of fuel poverty a year, with an ambition to upgrade all such homes and end the scandal of cold homes within 15 years, saving the average household over £270 a year.
    • Interest free loans to cover the costs of energy efficiency improvements for up to one million households during the next Parliament.
    • A new target to upgrade properties in the private rented sector to a minimum of an Energy Performance Certificate (EPC) C by 2027.
    • Energy efficiency designated as a national infrastructure priority under Labour’s proposed National Infrastructure Commission.
    • Streamlined regulations and a long-term strategy to support investment in energy efficiency in non-domestic buildings.
    • Provide half a million personalised home energy reports a year, detailing how households could save money on their energy bills through insulation and
      energy efficiency.

    Sexual health

    Ambition: We want to ensure that everyone, particularly young people have the information they need to make informed and safe choices about their relationships and sexual health.

    Our ambition is to stop and then reverse the rise in cases of sexually transmitted diseases including syphilis and gonorrhoea and to significantly reduce the level of undiagnosed and late-diagnosed HIV.

    Protecting children

    Empowering all

    • We will make reducing undiagnosed and late-diagnosed HIV a national priority, working to challenge the stigma of HIV and promote increased availability of testing.
    • We will tackle inequalities in access, quantity and quality of sexual health services across the country and promote better linkages between contraceptive and sexual health services.

    Mental Health in Society

    Good mental health doesn’t start in hospital or the treatment room; it starts in our workplaces, our schools and our communities. So we need a mental health strategy outside as well as inside the National Health Service. The Taskforce on Mental Health in Society, led by Sir Stephen O’Brien, was set up to explore how society needs to change to prevent mental health problems and promote good mental health, and how we can better support those affected by or recovering from mental health problems.
    Three findings have consistently emerged from the work they have done in these areas:
    1. Population mental health: A wide variety of social and environmental factors can affect mental health, so interventions to address these and build resilience can promote good mental health and help to prevent mental health problems
    2. Early Intervention and action. Early help and support to tackle problems upstream is far better both for individuals and families and for the country as a whole than allowing problems to develop
    3. Supporting those living with mental health problems: There already exist inspiring examples of how people living with mental health problems can be supported to live fulfilled lives, but we need a radical shift in attitudes, policy and practice if we are to make this a reality for all
    The Taskforce has explored how these three issues figure in some of the major  contexts in which we live our lives: home, community, school and workplace – both the problems that exist and the opportunities to be grasped if we act. Their final report will be published in early 2015.

    A public health system that works for communities & families

    Labour wants to give Directors of Public Health more influence when it comes to tackling public health problems and we want to strengthen the position of Public Health England in wider policy-making and public debate.

    Directors of Public Health

    In January 2013, the Association of Directors of Public Health published the results of a survey of its members which found that only 17% believe their Council understood the importance of public health (down from 33% the previous year). A key reason for this is that many Directors of Public health are subordinate to other officials within local authorities and have not been incorporated into local government with the level of seniority and influence that is needed for them to work effectively. The Association of Directors of Public Health found that less than half of Directors of Public Health report to the CEO or equivalent post. 20% report to another Director, usually the Director of Adult Social Services.

    Labour will ask Public Health England to investigate the governance and accountability arrangements of Directors of Public Health to ensure they have sufficient influence. Directors of Public Health must be free to speak out without fear or favour on the challenges facing the health of their local population. Directors of Public Health are currently required to write an annual report, which is published by the local authority. As part of the annual reporting requirements, Labour would expect the Director of Public Health to  include forward planning in this process, setting out the public health problems facing their community and outlining the action needed over the coming year to tackle them.

    Public Health England

    The Health Select Committee has said that: ‘Public Heath England was created by Parliament to provide a fearless and independent national voice for public health in England’ but ‘does not believe that this voice has not yet been sufficiently clearly heard.’ A key criticism of Public Health England has been its failure to speak out against government policy decisions on public health, such as delaying the introduction of standardised packaging of tobacco.

    At present Public Health England is an executive agency of the Department of Health and some organisations, including the Faculty of Public Health and the British Medical Association, have called for Public Health England to be given greater independence. Labour will review whether the status of Public Health England as an executive agency is appropriate and consider what further steps are needed to ensure Public Health England is able to provide policy advice free of political considerations. This review will include consideration of whether the regionally-based Public Health Observatories, that under the previous Government provided information and analysis on public health programmes, should be reestablished and given responsibility for providing public health surveillance and intelligence functions in support of local authorities and other public and community bodies.


    Since the coalition government came to power almost five years ago, child poverty has increased to 3.5 m. Nationally, around a third of children live in poverty, with levels as high as four in ten children in London. Most of these children (around 63%) live in working households. If the coalition policies continue, Barnado’s predict another 1 million children will be pushed in to poverty by 2020.

    According to new research published by Kellogg’s, four in ten teachers say they see children arriving hungry at school every day. The vast majority – almost 7 in 10 – of these teachers said this was due to families struggling financially and over half linked hunger to changes to benefits. The overall picture of child hunger looked bleaker to the teachers surveyed now than it did a year ago and only one in five teachers said they never saw children arrive hungry at school.

    This is what poverty means to all too many children and in London an earlier survey for the London Food Board found that 74,000 in the capital of the sixth richest country in the world often or always went to be hungry. If a country can’t ensure its children are fed, it does not deserve to be called civilised. Feeding Britain, the cross party investigation in to food poverty led by Frank Field MP and the Bishop of Truro, highlighted the significant issues facing our society. The report’s introduction states that ‘it is time to look again at the state of our country and to review the fundamental values that led to the creation of our welfare state.’

    One of the greatest confidence tricks of this government has been the demonisation of the poor and the remarkable feat of setting people on low income against each other while overseeing a continued rise of inequality. This inequality means that just two days in to the working year, on ‘Fat Cat Tuesday’ as it was dubbed by the High Pay Centre, top executives had earned £27,000, the equivalent of a year’s average earnings. Meanwhile, the number of people in work but earning poverty pay is rising.

    After a week when some commentators have suggested there is little difference between the main parties, it is worth reminding ourselves of the need to place our Labour values to the core of what we say over the next few months. Not just for those conversations we will be having on the doorstep but to remind ourselves why we have to fight for a Labour victory.

    This week’s political message from the Labour Party was about the NHS. It is clear that this will be a central theme of the election campaign, however, it cannot be the only issue on which we fight. We need to present a values based vision of what we want the country to be like in five years’ time – a country that is fairer, more equal and in which people have enough money to feed themselves and their families.

    Part of this vision needs to reflect the values that are clear from some of the successes we had in government. The Conservatives and the Liberal Democrats are not going to do this for us but it is an important part of demonstrating how our values and our record underpin where we want the country to go.

    Child poverty is not inevitable. It is possible to reduce it. Labour reduced the numbers of children living in poverty by 800,000 when we were in power. Not only does the Government have a statutory duty to end child poverty by 2020, from a moral perspective as well, it has to be our goal to eliminate it.

    It’s easy to be despondent about where we are headed in the polls. I am tired of people debating which party they would rather be in coalition with. I am tired of people suggesting that it might not do us any harm to be in opposition for a few more years. It might not do some of us harm individually but it would do massive harm to the most vulnerable in society. If we are unhappy at what has happened to the fabric of our society in the past five years, we need to be clear that a future Conservative led government or coalition would take us further down their road to ruin.

    Last week, I visited Pecan foodbank in South London and was reminded about the individuals, many of them children, who are being left behind by the current government. Parents skipping meals so their children can eat. People down on their luck through no fault of their own who use up their savings when they lose their job and then have to wait months for benefits claims to be processed once their savings have run out. Individuals with mental health issues sanctioned – in some cases for years – when they get turned down by ATOS and can’t cope with the benefits system.

    It serves the current government for people to be despondent and cynical about politics. They don’t want people to see the difference between the main parties. It is up to us to make sure they do. To do this we need to be hungry not just to do reasonably well and maybe scrape in as the largest party but to do everything in our power to win an outright majority.

    The legacy of poverty in childhood stays with people throughout their lives. With millions of children already living in poverty, and all indications showing that many more are likely to join them unless the political direction of travel in this country changes, we are facing the fight not just for a Labour victory but for these children to have a better future.

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    Children learn their place in the world at a very early stage

    Early Cognitive Development of British Children

    Inequality in the Early Cognitive Development of British Children in the 1970 Cohort Author(s): Leon Feinstein Source: Economica, New Series, Vol. 70, No. 277 (Feb., 2003), pp. 73-97

    This graph shows that children from well off parents who score poorly on a range of tests at 22 months old improve their scores as time goes on. The scores of children of poor parents who did well before they were two years old steadily deteriorate.

    School readiness by parental income group

    Deprivation and Education

    The influence of deprivation on educational attainment at the age of 16  is shown very clearly here

    Per cent achieving 5+ A* - C grades by dep[rivation

    Deprivation and Education

    and of course it is not only educational attainment that is affected by deprivation

    Emotion adjustment in children by father's social class

    This data is from the 1958 birth cohort study

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    Free School Meals for All is a policy that helps both children and families – it is the ultimate ‘One Nation’ policy.  A Labour campaign is being launched to persuade Labour councils and the Labour Party nationally to adopt the policy of Free School Meals for All. This will be led by the GMB trade union, Fiona Twycross AM and Cllr Richard Watts (Islington).  The policy has the backing of a range of charities including Save the Children, Child Poverty Action Group and the Children’s Food Campaign.  There are three key reasons why we believe Free School Meals for All should be introduced:

    1)  Free School Meals for All gives children better learning and better diets:

    • It boosts school results: according to the Institute for Fiscal Studies (IFS) and the National Centre for Social Research (NatCen) free school meals for all “significantly increased attainment”.  Children in the two pilot areas looked at (CountyDurham and Newham) made between four and eight weeks extra progress at school than similar children in similar areas.  In just two years of schooling that’s a lot of extra progress.  Free School Meals for All also is found to improve children’s concentration, learning and behaviour – after all, which of us is at our best when hungry?
    • It also improves children’s diets with strong evidence that the policy increase the consumption of healthy food and sends a strong signal to families about the importance of healthy eating.

    2)  Free School Meals for All helps hard working families

    • Saving families £300 a year per child for school meals is a big help in tough times.  Most of the families that benefit are in the ‘squeezed middle’.
    • Means testing free school meals is a major contributor to the poverty trap and a disincentive to work.  Introducing Free School Meals for All will make it easier to make work pay for those currently unemployed.
    • Free School Meals for All removes the stigma of claiming free school meals, which prevents thousands of children claiming benefits they are entitled to.

    3)  Free School Meals for All is a good investment:

    • Free School Meals for All improves children’s learning and health, which will save the public purse a great deal in the future.  It has been said that the cost of childhood obesity alone will bankrupt the NHS unless radical action is taken.

    We think there are strong arguments on affordability and introduction of Free School Meals for All:

    1)   We can afford Free School Meals for All
    There is a cost estimated at £1 billion to ensure Free School Meals for All could be provided for both primary and secondary aged pupils.  This sum can be found from within current budgets in that it is less than the amount that the Public Accounts Committee found that Michael Gove has wasted in pursuing his Converter Academies programme.  There are also other sources of funding worth exploring e.g. the charity Sustain’s idea of a sugary drinks tax.

    2)   A Universal Benefit worth introducing
    Everyone believes there should be some mix of universal and targeted benefits; e.g. Labour still believes in universal free schooling and the cost of free school meals is minute compared to this.  It should be seen as part of the package of the state education offer not an additional benefit. At the moment means-tested free school meals increase the poverty trap, are a disincentive to work and penalise the working poor and families on the breadline.

    If you are interested in joining or supporting the campaign due to be launched shortly, contact: Richard Watts on; Fiona Twycross on or Gary Doolan on

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    Co–production addressing health inequalities

    Inequalities in health outcomes and health literacy are not often discussed in the context  of co–production for long–term conditions. Long–term conditions fall more heavily on the poorest in society: compared to social class I, people in social class V have 60 per cent higher prevalence of long–term conditions and 60 per cent higher severity of conditions. This tallies with the Marmot review which reported that the poorest people die on average seven years earlier, but more importantly, they have on average 17 years of disabled living before they die.

    Social determinants, such as poverty and educational failure are responsible for these poor outcomes but the common intermediary is health literacy which has been defined as the ability to make sound health decisions in the context of everyday life – at home, in the community, at the workplace, in the healthcare system, the market place and the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information and their ability to take responsibility. Continue reading »

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    Brief summary of research findings

    Dr. Katherine Smith University of Edinburgh

    Aims: This project set out to study the relationship between the mass of research on health inequalities in the UK and the policy responses which emerged in Scotland and England between 1997 and 2007, a period in which official commitments were made in both countries to reducing health inequalities and to employing research evidence in policymaking.

    Methods: Review of research literature, documentary analysis of 42 major policy statements, and 61 interviews with academic/other researchers, policymakers, research funders and journalists.


    How has health inequalities research influenced policy?

    • Very little evidence was found to support the notion that policies to tackle health inequalities have been based on available research in either Scotland or England but the data do suggest that research-based ideas have travelled into policy.  Whilst this may seem like a relatively simple distinction, it is crucial because once ideas are separated from the evidence on which they are based, they become far more malleable entities, transforming as they move. The clearest illustration of this process involves psychosocial determinants of health inequalities, a research-based idea frequently visible in policy contexts but largely only in connection to an emphasis on social capital, confidence and stress and not (as much of the research implies) to inequalities in income (or other social or material determinants).
    • Some ideas about health and health inequalities have demonstrated a remarkable degree of persistence over the past thirty years (e.g. medicalised, individualised and risk based approaches) whilst others appear to have faltered or splintered as they moved from research into policy (particularly those concerning ‘upstream’ social and economic determinants).
    • These different journeys (or fates) can be explained by focusing on 3 idea types ideas:

    (i)                 institutionalised ideas (embedded in the organisation of institutions and accepted as facts);

    (ii)               charismatic (transformative) ideas (which persuasively challenge institutionalised ideas);

    (iii)             chameleonic (transformable) ideas (which succeed in influencing policy discourse because they are easily amenable to varying interpretation and, therefore, adaptable to different points of view, yet these constantly changing interpretations limit their influence).

    • The data suggest that, for health inequalities in the UK, some ideas (e.g. medical models of health and market-based approaches to policy) had become so extensively institutionalised that the intellectual space from which charismatic ideas might have been expected to emerge has been constrained.
    • Hence, in the decade following 1997, the ideas about health inequalities which moved successfully from research into policy were either those which posed no challenge to institutionalised ideas or those with the metamorphic qualities of chameleonic ideas.

    How did the relationship between health inequalities academics and policy actors function?

    • Most health inequalities researchers wanted to influence policy and many had extensive and/or regular contacts with civil servants.
    • Far fewer had regular contacts with broader ‘policy actors’, such as politicians, the media, think tanks or advocacy groups (e.g. major charities and campaigning organisations).
    • Most academics felt under a growing pressure to demonstrate engagement with policymakers but they generally interpreted this to mean engagement with civil servants and ministers (and not the broader kinds of policy actors outlined above).
    • Some academics were wary about engaging with the media, both as a result of previous negative experiences and recognition that media appearances were not always well regarded by academic colleagues. Despite this, most academics were keen to engage with the media but felt unsure how best to do this for health inequalities related work.  Interviewees based in the media also suggested it was difficult to gain sufficient editorial interest in health inequalities.
    • The interviews with academics suggest that the dominance of institutionalised and chameleonic ideas is encouraged by the fact that, when promoting their ideas to policy audiences, researchers are extremely conscious of the need to be able to secure future research funding/posts. There was a widespread perception amongst academics that if they were overly critical of government policy, they risked being labelled ‘radical’ and losing policy and funding credibility. Hence, when engaging with policymakers, academics often described deliberately constructing less critical, more ambiguous ‘policy messages’ than when engaging with some academic colleagues.
    • In addition, the research highlights that policymaking organisations have a very limited institutional memory (due to the short time-frames within which policymakers are often required to work and rapid staff turnover). This enables the same ideas to be constantly re-cycled. Academics often have little incentive to highlight the recycling of ideas, given the pressures they feel under to generate research income.


    • Research tends to influence policy through the translation of ideas, which can (and often do) change as they move between actors.
    • Researchers need to recognise this and put more resources into tracking and responding to the evolution of ideas with which they are associated.
    • Policymaking organisations lack institutional memory. Addressing this could avoid resources being spent on research that is unlikely to offer much that is significantly new.
    • If researchers and funders want to encourage the development of innovative research and ideas, they ought to be at least as concerned with the influence of policy on research (which tends to cause researchers to focus on short-term policy goals) as the other way around.
    • If policymakers genuinely want researchers to offer clear policy messages, there needs to be a greater acceptance of the role and utility of challenging ideas.
    • If researchers want to promote challenging messages beyond academia, they should consider the potential role of broader policy actors (particular advocacy organisations, think tanks, politicians in opposition and the media) as well as that of civil servants and ministers.
    Fresh Insights

    How Fresh are these Insights?

    Extended Summary:

    Methodological approach:

    In addition to reviewing the health inequalities research literature, a two-part qualitative methodology was employed, consisting of: (i) the documentary analysis of 42 relevant policy statements (25 from England and 17 from Scotland); and (ii) 61 semi-structured interviews with: academic and other researchers; civil servants; ministers; policy advisors; research funders; public health practitioners; and journalists.  The data from both approaches was combined, first to trace the presence of research-based ideas about health inequalities in policy and then to attempt to understand why some of these ideas appeared to have been far more influential in policy than others.


    I) Ideas-based policy: Despite official commitments to employing research in policy responses to health inequalities in both Scotland and England during the study period, there are extremely few examples within the data to support the notion that research evidence has informed policy.  However, this is not to say that research evidence has not influenced policy at all.  Instead, the thesis argues that it has been through the movement of research-based ideas that health inequalities research has influenced policy.  Whilst the observation that ideas (or knowledge-claims) are central to understanding the relationship between research and policy is far from new (e.g. Bartley 1988, 1992; Knorr-Cetina 1981; Rein 1980), it is worth re-stating in the context of the discussions about ‘evidence-based policy’ that were taking place during the study period.  The crucial point in making such a distinction is that, once ideas become separated from the evidence on which they are based, they are far more malleable entities.  Indeed, as Latour (2005) insists, for ideas to move between actors and across boundaries, they must be translated.  So, unlike metaphorical batons in a relay race that can be passed from one actor to another, the movement of ideas is more comparable to a complex game of ‘Telephone’[1].  Consequently, whilst many of the well-known theories about health inequalities are identifiable within policy contexts, they have all undergone varying degrees of transformation in their journeys into policy, some far more than others.

    II) The varying journeys into policy of research-based ideas about health inequalities: The following six distinct journey types capture the varying ways in which research-based ideas about health inequalities have moved into policy:

    (i)            ‘Successful journeys’ involve ideas that are visible both in policy rhetoric and proposed interventions and which appear to have changed very little in their path from research into policy.  Furthermore, these ideas are applied to policy interventions in ways which are consistent with their theoretical construction in the research literature.  Consequently, the ways in which these ideas are articulated in policy contexts is not dissimilar from the ways in which they are described in the research literature (or by academic researchers in interviews). Only one example of a ‘successful journey’ was found and this relates to the importance of intervening in the early years of life.

    (ii)          ‘Re-contextualised journeys’ involve ideas which seem to have been applied to policy interventions in ways which the research evidence does not necessarily support.  For example, whilst research evidence suggests inequalities in healthcare can play an important role in exacerbating health inequalities, there is very little support in research for the policy decision to focus on the health services as a central means of tackling health inequalities.  Nevertheless, this body of work appeared to have been reinterpreted (i.e. translated) within policy contexts in ways which suggested it did.

    (iii)        ‘Partial journeys’ refer to ideas that have not been substantively transformed during their journey into policy.  However, these ideas appear to have exerted far more significant influence on policy rhetoric than on related policy interventions. The key example of such a journey related to social and economic determinants of health inequalities.

    (iv)        ‘Fractured journeys’ are those in which the translation and transformation of ideas is most overt.  In these journeys, it is apparent that accounts of the idea (or set of ideas) within policy contexts are substantively different from (and at times even in conflict with) descriptions within the research literature.  Consequently, whilst frequent references within policy statements to terms associated with an idea might suggest that it has ‘successfully’ travelled into policy, further analysis reveals the ways in which such ideas are conceptualised within policy contexts differ significantly from the ways in which they are articulated by researchers. The most overt example of this kind of transformation involved psychosocial ideas about health inequalities, which appeared to have travelled into policy in ways which emphasised only the importance of notions of social capital and social support but which did not relate this to the importance of tackling inequalities in socio-economic factors.

    (v)          ‘Weak journeys’, as the name suggests, refer to ideas which are only just detectable within policy and, hence, appear to have exerted only minimal influence.

    (vi)        The term ‘non-journeys’ was employed to describe ideas that were clearly visible in the health inequalities research literature but which were not present in the policy data.

    Table 1: The varying journeys into policy of research-based ideas about health inequalities

    Journey type Research-based idea(s) about health inequalities*
    • Importance of focusing on the early years of life (although the data are unclear about the extent to which the source of ideas about the importance of early years within policy contexts was linked to research-based ideas about health inequalities)
    • The role of lifestyle-behaviours
    • The role of health services / clinical interventions
    • The importance of socio-economic & material determinants
    • The role of psychosocial determinants and relative socio-economic position
    • The importance of focusing on the lifecourse
    • The role of social selection / mobility
    • Cultural explanations (more discernable in Scotland than England)
    • Intelligence (IQ) based explanations
    • Structural / ideological explanations
    • Place / contextual determinants (NB area-based interventions clearly identifiable in policy but do not appear to be based on ideas about contextual effects)

    *Categorisations are based on a review of the existing research on health inequalities, which forms Chapter Two of the thesis.

    III) Explaining these contrasting journeys

    (i) Constructions and understandings of health inequalities

    The way in which health inequalities have been constructed and understood as a policy problem has inevitably shaped potential policy responses.  As Graham and Kelly (2004) emphasise, a conception of health inequalities as the consequence of ‘health gaps’ resulting from the ‘health disadvantage’ of some groups (rather than as ‘social gradients’ which traverse society), encourages policy responses which focus on trying to achieve health improvement amongst particular groups or areas.  This contributes to a blurring of the twin policy aims of ‘improving health’ and ‘reducing health inequalities’, enabling research-based ideas relating to health improvement (particularly lifestyle-behavioural interventions) to be ‘re-contextualised’ within policy as logical responses to health inequalities.  This situation appears to have been further exacerbated by the short-term nature of national targets for reducing health inequalities (in both countries) and the decision to place responsibility for meeting these targets with NHS bodies.

    (ii) Academic research – a restricted arena for the emergence of charismatic ideas?

    The possibilities for undertaking research on health inequalities during the study period were frequently presented positively in comparison to 1979-1997, when Conservative governments were in power.  Nevertheless, the data from interviews with health inequalities researchers suggest many felt unable to approach the issue as freely as they might have liked (or as is often assumed in literature concerning the relationship between research and policy) even after 1997.  Rather, many reflected that they pitched proposals for, and wrote-up accounts of, research based on their perceptions of what would, and what would not, be deemed credible amongst the following key audiences: other academics; organisations/individuals with the potential to fund research; policymakers; and sometimes (although much less frequently) the media.  This demonstrates that it is necessary to think about the relationship between research and policy as an ‘interplay’ (Rein, 1980), rather than as a unidirectional movement of ideas from research into policy, and that the role of research funders in this ‘interplay’ also requires attention.  This raises some important questions about the impact of calls for ‘evidence-based policy’ on the production of research-based ideas.  Echoing Hammersley’s (2003, 2005) concerns, the data suggest that the promotion of the notion policy ought to be better informed by research may well have contributed to an ‘imaginative squeeze’ in academia.  For the flip-side of this approach has been a pressure on researchers to become more attuned to, and informed by, ‘policy needs’, thus reducing the potential for innovative, transformative (or ‘charismatic’) ideas to emerge from research.  Combined with an increasing pressure to disseminate academic work to ‘research users’ and the media, this situation helps explain why several of the academic interviewees claimed to have packaged and promoted ideas in ways which made them appear less challenging to policy than they had the potential to be.  This process contributes to explaining both the ‘fractured’ and the ‘partial’ journey types that were identified.

    (iii) The constraining effects of institutionalised ideas

    The interviews with policy-based interviewees suggest a risk-based, medical model of health is deeply institutionalised within the policymaking bodies responsible for health inequalities in Scotland and England.  This significantly shapes the potential routes into policy that research-based ideas about health inequalities are able to take, resulting in a situation in which only ‘bounded innovation’ is encouraged.  In other words, ideas which can easily be fitted within risk-based, medical models of health are likely to be translated into policy far more easily than those which present (or require) alternative ways of thinking about health.  The interview material suggests that this situation may be exacerbated by a lack of any formal interface between research and policy, resulting in a dependence on bi-lateral relationships between individual researchers and policymakers who are operating from specific divisional locations.  In this context, it is not surprising that holistic, cross-cutting ideas about health inequalities (such as those relating to socio-economic and psychosocial determinants) have encountered significant barriers in their journeys into policy.  Thus, this helps explain both the ‘re-contextualised’ journeys of ideas concerning the role of lifestyle behaviours and health services and the ‘partial’ journey of ideas concerning socio-economic and material determinants of health inequalities.

    (iv) The limited institutional memory within policymaking organisations

    Once an idea has travelled into a policy context, the lack of vertical and horizontal connectivity within policymaking institutions serves to limit its circulation.  Furthermore, a lack of institutional memory within policymaking organisations (caused by rapid staff turnover and short-term deadlines) enables ideas that have previously been circulated to re-appear as ‘new’ ideas.  The combination of the lack of policy connectivity and institutional memory mean that the translation of an idea between research and policy does not necessarily secure its translation into policy in any broad sense.  Instead, the same research-based idea might travel into policy through various different routes, or recurrently over time, potentially being translated (and therefore understood) in a number of contrasting ways and without necessarily having any significant influence on policy outcomes.  This helps explain how and why the ‘fractured journeys’ identified might have occurred.

    (v) Wider political and social ‘contexts’

    Finally, the data demonstrate that many of the interviewees believed the wider social and political ‘contexts’ in which they were situated were relatively hostile to the reduction of health inequalities.  More specifically, a significant number of the interviewees said they believed that these ‘contexts’ acted to ‘block’ some of the most widely supported research-based ideas about health inequalities, namely a belief that material and socio-economic deprivation, or inequalities in these factors, are the underlying cause of health inequalities.  The word ‘contexts’ has been placed in inverted commas because the interviewees’ descriptions of what these ‘contexts’ involved were vague, encompassing references to global economic processes, financial institutions, the mass media and social and political cultures/beliefs.  The data collated for this thesis do not facilitate a detailed exploration of this issue but they do suggest that the way interviewees acted and interacted, based on their perceptions, is likely to have contributed to the ongoing domination of particular ways of thinking about health inequalities.  Two perceptions seem particularly important: one is a belief, or acceptance, that a medical approach to health ought to be (or is) accorded higher status than other types of knowledge; the other concerns the centrality of the economy to public policy.  Each of these appears to have been institutionalised well beyond the physical organisation of policymaking bodies, shaping research accounts of health inequalities as well as policy responses.  Indeed, the extent to which economic discourses were evident within the language employed by interviewees from a wide range of sectors suggests that this way of thinking is so deeply embedded in society that it is almost impossible to avoid using language that reinforces the hegemony of this way of thinking.

    IV) A Weberian theoretical framework: Drawing together these various explanations, an ideational theoretical framework was developed, involving three distinct genres of ideas: (i) ‘charismatic ideas’; (ii) ‘institutionalised ideas’; and (iii) ‘chameleonic ideas’.  Inspired by the work of Max Weber, the first two genres are antithetical to one another.  Institutionalised ideas are those which have been able to move so successfully across boundaries that they have become embedded within the organisation of institutions and the language with which actors communicate their ideas.  Once embedded, ‘institutionalised ideas’ move between actors and across boundaries in ways which work to maintain, reinforce and embed their appearance as ‘facts’.  This ongoing process affects the movement of ideas that have not yet been institutionalised by encouraging the translation of those ideas which complement (or at least do not overtly challenge) the institutionalised ideas, whilst simultaneously working to ‘block’ ideas which do present a challenge.  Accordingly, the findings suggest that ideas about health inequalities which fit within the boundaries of ideas that have already been institutionalised (i.e. the primacy of the national economy and a medical model of health) have found it far easier to travel between actors and across boundaries (experiencing only minimal transformation in this process) than ideas which do not.  This process helps ensure that ‘charismatic’ ideas, with the potential to radically challenge institutionalised ideas, are unlikely to emerge.  Instead, ideas which might have become charismatic (such as psychosocial determinants of health inequalities) are promoted in ways which emphasise their vagueness and flexibility, thereby facilitating their continuing circulation despite less than hospitable circumstances.  These ‘chameleonic ideas’, deliberately imbued with mercurial qualities, constitute the third strand of the theoretical framework.

    Implications for research and policy

    • It would be both more honest and possibly more helpful for conversations concerning ‘evidence-based policy’ to be replaced with discussions about ‘ideas-based policy’.  Not only does this phrase help focus attention on the centrality of ideas to understanding the relationship between research and policy but it places a spotlight on the characteristics and qualities of different ideas.  This should help highlight the influence of ‘institutionalised ideas’ on the emergence and circulation of other ideas; an influence which appears to have been effectively obscured by discussions about ‘evidence-based policy’.  The purpose of such a shift would be to enable conversations to take place outside the boundaries of ‘institutionalised ideas’.  In other words, a focus on ‘ideas-based policy’ might help facilitate more imaginative research spaces to develop, spaces from which charismatic ideas may be more likely to emerge. So, rather than the kinds of conversations which ‘evidence-based policy’ appears to have encouraged, in which certain ideas are treated as unchangeable facts (and, consequently, others as impossible dreams), ‘ideas-based policy’ might open up the opportunity for more radical and imaginative dialogue.  Such a shift does not imply that research is in any way an unnecessary activity that could be replaced by abstract philosophical debates about the merits and deficiencies of particular ideas.   Rather, as Weber (1968) argues in Science as a Vocation, the role of science in society is not to tell us precisely what we should do or how we should live, but to provide us with information that makes more meaningful choices possible.
    • Given the emphasis that academic interviewees placed on the role of funding opportunities in shaping their research and communication, this is an issue which has so far merited less attention amongst academics, policymakers or researcher funders than is warranted.  This is particularly so in light of the growing pressure on academics to ‘disseminate’ their work beyond academia.  Such discussions are likely to involve some reflection on the desirability (or otherwise) of different kinds of academic (intellectual) spaces.
    • With regards to policy, the findings point both to a need to increase the institutional memory of policymaking organisations and to improve the means by which research-based ideas are circulated within policy.  These issues both relate to the way in which policymaking bodies are structured and are, therefore, inevitably difficult to address.  However, not doing so is likely to result in the continuing (re)circulation of ideas which fit within existing ways of thinking and, therefore, a failure to encourage, and engage with, alternative ways of thinking.   Not only do existing circumstances serve to constrain the potential for innovation within research and policy, they also encourage the expenditure of policy resources on research which is unlikely to offer anything that is significantly new.


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    [1] ‘Telephone’ is a game in which one person whispers a message to another, who then whispers it to another, who whispers it to another and so on.  The conclusion of the game is marked by a comparison of the eventual message relayed to the final participant compared with the actual message of the first speaker (the point of the game being the extent to which messages are transformed as they are communicated).

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