Reducing Inequality Friday 31st October 2008 Sheffield Quaker Meeting House

Verbatim transcript of Kieron Williams contribution and discussion.

MARTIN: Kieron, do you want to come and do your thing?

NEW SPEAKER: Can I ask a question? I’ve learnt something yesterday that I’m not sure whether it’s just for Greater Manchester or whether it’s statutory, but one of the big issues in commissioning different sort of levels of primary care according to inequalities is that apparently you cannot shift the funding by more than 1% a year on a practice-based level. So there’s like a brake in the system, if you see what I mean. I was talking to one of our commissioners yesterday —

MARTIN: You mean the MPIG. What’s the proper name for it? Minimum practice income guarantee. But it’s about to be abolished. Alan Johnson announced about a month ago he was going to abolish it.

NEW SPEAKER: When’s that coming in then?

MARTIN: Next year or two.

NEW SPEAKER: I was just wondering whether it was universal …

MARTIN: They developed this complicated formula to reward GPs who are looking after more deprived people and then they put in a system to prevent it working, essentially.

NEW SPEAKER: Exactly, yes. Well, I only found out about it yesterday.

MARTIN: Don’t worry: Alan Johnson’s on the case. It may be the best thing he’s done, actually. Kieron, you are going to tell us a bit about Health Sheffield First Partnership.

KIERON WILLIAMS: I work for the both the Sheffield City Council and Primary Care Trust jointly and I was just going to talk a bit about work in Sheffield. I did have something I brought with me this morning and, listening to your talk, I realised I might have missed the point a bit. So I’ve kind of changed it a bit during the course of the beginning. So if I lose my way, I apologise. I also apologise to anyone I distracted when I was doing it at the back earlier on.

I want to start with this because I don’t think it was mentioned. This is looking at mortality from the three major causes of death in the UK as a whole and just tracking — four causes of death really and on three of those over a century, circulatory infections, respiratory. Cancer staying much the same across the middle. But this is just showing inequalities in health between the different social groups in the UK generally. So the top black line is the top social group and bottom grey line you can’t quite see is the unskilled manual group. I suppose the important point is from the seventies to the most recent data I found we’ve gone from having a 2.4 year difference in life expectancy to a 4.4 year difference. Coming back to that point in terms of health inequalities, we’re widening the gap as a society.

MARTIN: Does that really show a sudden drop-off in the class 1 life expectancy?

KIERON WILLIAMS: They are all improving. So life expectancy —

MARTIN: That’s gone flat.

KIERON WILLIAMS: It hasn’t improved in that gap. It may well improve in the next one. I wouldn’t be able to say too much about that. Everybody’s life expectancy has got better. It’s just the most affluent people’s life expectancy got better more quickly and what you have ended up with is a bigger gap.

So just to go back to Sheffield again then, for some time Sheffield has been a healthy city and has adopted this approach and way of working. Sorry, go back to this again.

So it’s talking about health in Sheffield pretty much reflected in the national picture in a sense that now Sheffield is healthier than it has ever been. Infant mortality is low. All these measures of health, if you look at our average population, health in Sheffield is as good as national average which is good, for the first time in history probably.

But if you look at different income groups in Sheffield, and the same story again here, the most affluent part of society has the highest life expectancy and the least affluent part has the lowest expectancy. It’s a pretty straight line. If you are in the bottom fifth, you will die sooner. It’s a fairly simple divide within our city.

This is a map of Sheffield. For those of you who don’t know Sheffield, I will try to explain it. Each of these coloured areas is a neighbourhood in the city. These big ones are pretty much in the Peak District, this area here is the city centre, this is the more affluent urea of Sheffield in the south-west that borders on to the city centre —

MARTIN: David Blunkett’s constituency.

KIERON WILLIAMS: — which is around here and this is the kind of old industrial area that goes into the lower Don valley. What this is saying is these pale areas have a life expectancy of 69 to 75 years and these dark area have a life expectancy of 80 to 87 years. So there’s big gaps across the city. If you were to take it down to one of these individual neighbourhoods, I think the gap between the neighbourhood with the lowest expectancy and the neighbourhood with the highest expectancy is now 11 years. Reflecting on the, gap that is equivalent to the gap between the UK and sub-Saharan Africa. So the gap within our city is the same between – what we consider a very shocking international gap.

Then looking at this — and this is very much in line with Richard’s point really — this is not a map of health, this is a map of a basket of a whole range of indicators around income, housing, education all weighted together and basically the point is you see exactly the same neighbourhoods having the same level. I can put up a map like this for you with data around how well kids do at school. You would see the same picture – or levels of unemployment benefit take-up or – a whole range of them. You see the same picture. The inequalities are the same.

NEW SPEAKER: A lot of our differentials are counted for by liver-related diseases, liver cirrhosis, etc. Do you have the same?

KIERON WILLIAMS: Individual health conditions there is a little bit of —

NEW SPEAKER: No, cirrhosis is sort of …

KIERON WILLIAMS: They all tend to map with the same spread across the city. The point really is there are huge inequalities within Sheffield both if you look at it in terms of income and if you look in terms of neighbourhoods in the city and those differences are just the same depending on whatever measurement of deprivation you look at. Health is no different. So it does come back to why there are inequalities.

Just a little thought really about what a healthy place to live is and I think I guess we all have images of what an unhealthy place to live is and there are just a few of those. This is Sheffield flooding a couple of years ago which had real big impacts on some of the much more deprived estates along the river edge. It was little reported in many ways.

But actually defining what a healthy place is can be quite difficult. The only images that have come up have been socially cohesive, always images of people relating well together and being part of a place.

So coming back to what I would see as what we are trying to do as a city is have this holistic approach to improving health that’s very much about good health and well-being for all and that’s quite fundamental. Obviously we’ve achieved good health for the affluent in Sheffield but actually how do we achieve good health for everyone in the city? A recognition that delivering that is not really about health services. We’ve had 60 years of the Health Service now and we have wider health inequalities than when the Health Service started. It’s important and we can improve the Health Service in many ways and help it contribute but it’s not going to be the driving factor.

There are actually a whole range of partners have a role to play in that local authorities have a lead role in shaping this for their area. What I want to talk about mostly is all of that needs community empowerment for that to work.

So I will skip past that.

So I’ll just talk briefly about this one particular programme that we’ve had in Sheffield for around about ten years now, I think, which is a community development and health programme and it’s been run in various different bits of the city. I think it started off in City Council now centrally co-ordinated by the Primary Care Trust. It’s essentially delivered by local community organisations and it’s a programme around about 1,000 people in Sheffield have been through now and it’s based on a course which is fairly simplistic in a sense.

But it’s a course that’s about taking people from a low level of awareness around health and their confidence around health to feeling empowered at the end. What it isn’t is a course that tells people how to cook healthy food, or how to be active or kind of simply health messages that you might get through many forms of traditional health promotion or how to stop smoking. What it is is a course that starts asking people questions about what they perceive affects their own health, how healthy they think their community is, how they think they can change that, how they think they can change the health of their family. You know, I won’t claim to be the expert about how it’s been developed and how it’s delivered in practice, but what I’m very aware of is going along to the beginning and end of the course, going to the sort of graduation ceremony for people who complete. What you see coming from that is people’s self-esteem radically transformed for a process that’s actually more about valuing them as people, giving them the confidence to feel that they can change their own health, the health of their family and the health of their community and what we’ve come out of it with a very real level in Sheffield is a whole raft of empowered community activists then very keen to go out in their communities and improve people’s health.

For us the next step of that now is we’re in a process of trying to support a network of volunteers that people have asked for. Saying “I’ve come out of this programme, I want to go out into the community and need that support”. We are now trying to set the network for people to be community health champions at the end of that.

I think it is important to reflect on the impact of it all. Roughly speaking, we see around one-third of the people that come out of that course go into employment in the not too distant future afterwards. Around a third go into some other form of educational learning and training and for many people that’s people at the beginning of it who felt that any kind of formal education or work wasn’t for them.

MARTIN: How do they get into this course, Kieron?

KIERON WILLIAMS: There’s a mix. We have had people referred from some of our more enlightened GPs, people brought in by some of the community organisations who have been working with them who are talking to people who want to make a life change but feel very they don’t know where to go with that and don’t know how to get out of being a single mother stuck at home and they want some kind of route in at the early beginning. So areas like Healthy Cross, if anyone from Sheffield has heard of that, a community organisation that runs holistic support for people to improve their health, takes a lot of people into the course. So it’s a kind of range. Some people just come across information about it themselves and say they want to go along, I suppose.

But I guess what just strikes me about and I did want to show you a short video we had about it but I couldn’t find it when we were looking for it yesterday, you see a real transformation in people’s personal confidence and Richard’s point about how empowered they feel that then has, as far as we can tell — we’ve not measured it in the kind of years passed difference — but people come out reporting better healthy living as a result of coming through that. It’s very different from the purely medical approach. I will leave that at that.

NEW SPEAKER: I was thinking health is a difficult subject to tackle because I think a lot of people see it as a non-priority really. There’s like housing and debts and chaotic lifestyles a lot of the time and they think their own health falls on the back burner.

KIERON WILLIAMS: I think in many ways that is important. I talked to a GP at an event a couple of weeks ago who was saying how he gets very frustrated about colleagues who have somebody comes in to see them and they diagnose them as having diabetes and they talk to them about treatment of diabetes but not the fact that person lost their job the week before and actually that person is never going to do anything about managing realistically their diabetes if what they are concerned about is the fact that they are unemployed.

NEW SPEAKER: And mental health as well.

KIERON WILLIAMS: You can go for a more helpful process with someone is saying what we will deal with now is your stress about being unemployed, but we will also look at what we can do around diabetes now and come back in the longer term to what we can do in more detail about that when we have dealt with what is most depressing for you at the moment in your own world view.

NEW SPEAKER: Falling into depression with all the other stuff going on, they are not going to be like at the table exercising. That will be the last thing on their mind, to go to the gym, although it helps depression. The motivation just wouldn’t be there initially.

MARTIN: Using GPs to do the sort of thing you are talking about, Kieron, is a very expensive way of delivering something that actually other people might do better because – GPs’ training. I spent 20 years in Citizens’ Advice Bureaux and things like that that is exactly what we did for a lot less money than GPs.

NEW SPEAKER: Can I say to Amanda the community empowerment system I think is a fantastic way forward, using themselves to cross-question what it is that they want to do and want to move forward with and I’ll give you one example from Bradford.

There’s a women’s centre, mostly Asian women, but not absolutely Asian women, that has been set up through Sure Start actually originally but, you know, sussing out what it was that local women wanted. One of the things they wanted was a gym in this particular centre and the gym works so well. It really is a model for everybody and it’s because it’s literally come from the bottom up, you know, and it’s been devised in a way where women feel safe about going in and using it and in their own time anyway, advice and meetings and English classes and what have you.

NEW SPEAKER: Don’t get us wrong — I think all the other things need to be controlled as well as supportive of that.

NEW SPEAKER: But I’m not contradicting what you were saying it’s just that if you can get in at the right point and enthuse people, I suppose, I think it can be really surprising what they can develop for themselves.

NEW SPEAKER: Can I just say to go into people’s homes and support them with independent living if they’ve an issue with weight, budget, if they’ve got an issue with anything that’s stopping them from living independently, we work with them to try to sort of build up confidence and self-esteem to do that. But I don’t know whether many other councils have that in place.

MARTIN: You would have hoped that most Social Services people would take that approach. Whether they do really I don’t know but that’s the plan, isn’t it? If you talk to what is now called Adult Social Care these days, it’s all about empowerment, they say.

NEW SPEAKER: It is but I don’t think they have got the resources. I think they are quite restricted.

NEW SPEAKER: It’s individual empowerment though. That’s the difference, isn’t it? It’s the difference between doing something collectively and doing something individually.

MARTIN: But the course you are describing is a course for individuals, it’s not a course for a community. What you are sort of doing is seeding people into part of Sheffield, I guess?

KIERON WILLIAMS: I suppose the aspiration — it’s not happened yet so I can’t tell you if it will work or not, but the Community Health Champions Network bit that follows on for some of these people and others who might not have been through the course yet but it’s meant to be much more about providing people from the communities that are getting a poor deal around health in Sheffield with a stronger voice. You know, it’s partly about championing health in their own community but also about championing the needs of that community and challenging the poor environment or poor services or the other inequalities that lead to poor health.

MARTIN: Although we don’t give people many levers on the Health Service. If the people of some part of Sheffield decided their services were crap, which they might be, they don’t have any way of doing anything about it in any obvious way, do they?

KIERON WILLIAMS: No, I think that’s very difficult. There’s an example of an area in Sheffield, I won’t give the detail of, but there is concern that it doesn’t have good primary care coverage and it’s very difficult to have a discussion about how you resolve that problem.

Mahroof Hussain:: On that one I can come in because one of the responsibilities for local groups is scrutiny and if you are finding there are differences in health provision or any services scrutiny have that responsibility to look into that. One of the questions I wanted to really ask, the higher level one, is who is ultimately responsible to tackling these health inequalities because it seems to me everybody is passing the buck either as PCT or Local Government and we need a review. In 2003/2004 about reducing health inequalities, we identified various gaps, looked at all the determinants produced a high level set of recommendations. Some of those have been implemented but some of those nobody has really specifically taken that responsibility. Everybody says yes, it should be a partnership approach, we should do XY and Z but over the last four years the gap has grown.

MARTIN: Where are you?

Mahroof Hussain: In Derby City. The actual health gap has increased between the deprived areas and affluent areas albeit by a couple of years. Either we have got better at measuring or things have gone worse.

NEW SPEAKER: The Director of Public Health, the Strategic Health Authority was responsible and presumably still is responsible. Is it they are just not held to account?

NEW SPEAKER: Local strategic partnerships is the key mechanism for the NHS and Local Government and other key partners to come together to produce a strategy to address a whole range of issues about the economics, environmental, health and social well-being of its population. That’s what the legislation says in 2000 in the Local Government Act. Local Government are given the key driver in relation to securing the well-being of its population but through a partnership arrangement.

KIERON WILLIAMS: What I would say about that though is I think the NHS is at the moment trying to make an effort to have an impact on health inequalities and you can have an argument whether they are doing it well or not but I think there is a genuine push, certainly in this region. In Sheffield as a city, for example, the whole PCT strategy, equivalent to what somebody said earlier, it’s based on reducing health inequalities – that’s the headline – and I think that’s true across much of the country. However, the NHS primarily has effect over health services which are one very small bit of the equation and, going back to Richard’s point, health services are a kind of tiny proportion of the bit about why we have health inequalities in the first place. I think other partners Local Government included, I think, Local Government the idea of having a role around health is relatively new to many bits of Local Government.

Catherine Gleeson: Where does the links, the new local whatever it stands for …

MARTIN: The local involvement networks.

Catherine Gleeson: I tried going to the links and finding out where I live what it’s like and it did seem to be very as if it hadn’t got off the ground at all. If you read the —

MARTIN: One or 2 of us are in our local link.

NEW SPEAKER: It hasn’t ‘yet started to operate and it’s having little impact and framed in such a way that it’s not supposed to have.

NEW SPEAKER: Just to get back to the point you are making about the LSPs and bringing us back to what Richard was telling us, if we could get the economic partnerships within the LSPs to take reducing income inequality seriously, then we would be in business. But they tend to resist that greatly. What they are prepared to accept is increasing skills levels and increasing average wage levels but the notion of reducing wages and income seems to them scaringly uninteresting.

RICHARD WILKINSON: I find all this discussion quite difficult. I realise the Socialist Health Association has a role in pushing Government policy trying to get little changes and I realise people working in health services have to do as best they can within the existing framework, but I think most of this sidetracks us from the real problem.

I remember talking to Len Sigh who was one of the central people in multiple risk factor intervention try a MRFIT study in the States which I think is still the biggest intervention trial trying to reduce heart disease. They went on for six years with people identified at high risk of heart disease. Their results were miserable. Len sometimes said on the rare occasions when we persuaded someone to stop smoking or something, we knew that a child is taking their first cigarette somewhere else in society.

I remember Ron Daw, an expert on all things Japanese, saying that Japan used to have this huge problem of adolescent suicides and I know if this had existed in Britain we would have set up studies trying to identify risk factors, whether we could tell which kids were at risk beforehand and maybe we would have set up, if we could afford to, hugely expensive counselling services in every school and college in the country. But, you know, you go on adding services, they are very partially effective. As you said, health services are not the most important influence on health in the country, police are not the most important influence on crime, none of these services are.

I suppose if you look at evaluations of programmes all over the world to raise self-esteem, they don’t work. People have put a huge amount of effort into trying to do something about it and it doesn’t usually have an impact. We don’t usually evaluate a lot of these community intervention programmes because it’s just totally unrealistic to think if you put a few community workers in that you are going to change the death rates in a population. You are not. Yet it allows us all to feel we are being busy, doing the best we can making a contribution. We are largely – not wholly but largely – misleading ourselves.

I do just feel at a loss to know — I can see that people in services have to do the best thing they can and yet this isn’t the discussion we should be having. That should be a discussion that takes place in people’s professional associations and things like that. But the Socialist Health Association should be doing something else.

MARTIN: Which is?

RICHARD WILKINSON: I thought this conference’s title was about reducing inequalities and I thought you meant income inequalities, material inequalities. We haven’t talked about that at all.

NEIL GOULBOURNE: Can I ask a question, Richard? As I said in my talk, I’ve often had exactly that thought and felt that this is a distraction from the real agenda.

Do you think that we should be arguing against these kinds of measures or should we just be agnostic about them?

RICHARD WILKINSON: You should do as much as you can in your professional association and with your colleagues.

NEW SPEAKER: But as the (inaudible) because they are obviously quite expensive.

RICHARD WILKINSON: Should be trying to play a much more educational role in terms of picking up the agenda that is being ignored elsewhere. But most of the issues we have been talking about are discussed in PCTs, in practices, in Government departments, in Government reports and this is the mainstream.

I remember Johann Markinvac in the six months that Britain was chair of or the presidency of the EU and one of the things Britain did to sort of showcase all we are doing about health inequalities. Johann Markinvac was asked to write the central paper for that and he reviewed European involvement in health inequalities and said Britain had the best and most developed policy of any country in the EU, but still it was hard to see any effect on health inequalities in Britain and that’s simply because most of it was not about tackling the underlying sources, it was trying to do things to stop inequality having the effects on health it does, just like people working on teenage pregnancies or drug things try and stop inequality, deprivation, whatever, having the effects it does have. That’s a very hard thing to do.

NEW SPEAKER: I think Socialist Health Association members should in their professional associations and on the committees that they sit on they should be absolutely explicit about the underlying inequalities and as well as arguing quite properly for community development programmes as a healthcare measure. They should be arguing very strongly, as I said earlier, about dealing with income inequality at district level and ultimately a regional level and beyond and doing heavy duty hard political stuff and being completely upfront about it and unashamed.

RICHARD WILKINSON: Who knows what cleaners are paid in their health trusts or in their practice?

NEW SPEAKER: Virtually nothing.

NEW SPEAKER: £5.52.

NEW SPEAKER: On, I think, three occasions I have been asked to review reviews for the Department of Health on evaluations of sort of subsidiary analysis of the New Deal Community Programme. I’m sure on two occasions I’ve wound into my comments that the research is probably reasonably modest the cost they have given the investment on the programme but I think, having got my calculator out, that perhaps it would be better rather than spending on these big programmes, is just give them money, it can be up to £5,000 per capita in a period just to those individuals here within these small communities. It is rather frustrating to repeatedly be asked to referee this stuff, comment on it and to write that. You do think this is all a bit strange. You get caught up in very large grandiose products. I feel quite sympathetic to what you have said, I’ve sat there, written comments back to the Department of Health within the comments saying wouldn’t it be quicker to just reallocate the money.

I fail to understand why we do not want to redistribute income in this country and I think you are right, I think we should be making that argument.

MARTIN: Why is it so scary to talk about it?

NEW SPEAKER: But why?

MARTIN: I suppose because the Labour Party in particular feel it’s lost lots of elections on that. That is probably what it boils down to. They feel if they talk about this they don’t get elected. If they do it, they will lose the next election. That is what they think.

NEW SPEAKER: That’s reproducing the problem.

NEW SPEAKER: Is that to get them arguments over — Richard’s argument getting them on to mainstream perhaps organisations should be trying to get broadsheet newspapers interested more in them ideas and because of the current climate perhaps they might be more receptive to that sort of stuff because if we were talking about Government spending, over a while you would end up reducing a lot of Government spending because all that indicators you wouldn’t have to have all these people doing all these things about all them sort of things because they won’t come down because you reduce the inequalities. So there’s an argument not many people know and when you do talk about that people sort of like — sometimes when you do point out the differences between the Nordic countries and UK and US and stuff, they say they can’t quite get it and say “Are you talking about communism?” and I’ve heard that comment. You know, that’s been a comment that people have made when you start talking about that sort of stuff. So we’re not getting that argument more mainstream about what health inequalities has done in society and we’ve not got it. It’s a specialised thing a few people know about really. A lot of people might know about it in general but don’t really want to take any notice of it, politicians particularly because it’s oh better not to talk about that, let’s talk about something else, let’s talk about health variations and all them sort of stuff.

I remember somebody at a conference recently saying that that is bashed into the literature these days variations against these authorities.

NEW SPEAKER: That’s the term the Conservatives used when they moved towards the new public health agenda when they realised we want to restructure the Health Service. We need to start making an argument so this is palatable. So they started talking about variations in health in part, I think, to use that as a logic for further restructuring the system. We have had an amazing amount of restructuring in the past 20 years. It’s amazing it’s still standing together if you look at how many times it’s been tampered with over the past 20 years.

MARTIN: Conservatives are now talking about health inequality. Iain Duncan Smith came to Manchester to give us a talk about health inequalities and what he said was fine as far as it went. He didn’t suggest he was going to do anything but he described the problem in a reasonably eloquent way and I just wondered what that meant really.

NEW SPEAKER: There are about 50 charities, including the one I represent, but including better known charities like Oxfam, Christian Aid and Shelter and so on have joined together in something called the Get Fair Campaign. The vision is to ensure no-one in the UK is marginalised or excluded from society due to poverty.

Our campaign calls for a decent adequate income for all homes and neighbourhoods to secure health and well-being and good quality services as a right for all. That is intended to influence the political process. I would be interested to know what Richard thinks of that kind of initiative.

RICHARD WILKINSON: I think it is important and I was writing it down thinking I must talk to you because we have been setting up something called the Equality Trust which sounds as if it would very much overlap with your aims.

But, you know, the Socialist movement was built on decades of educational work and based on a different analysis of society, different empirical material and also theory. Of course, politicians wanting to get elected they drop their educational function but we don’t have that problem. We can do it. I know academics are much freer of that than other people. It’s easier for us.

Incidentally, I forgot when talking about Japanese suicides, this man says how the Japanese lowered their suicide rates. There were changes in the educational system which made children’s progress through the system much more predictable so they didn’t feel they had let down families and humiliated themselves and so on. So there was a one-off change. I don’t know whether that was the purpose of the change or whether that was just a byproduct which substantially improved the problem. So not continuous ongoing costs as in providing endless counselling services or whatever. We have got to get down to the level of finding how these problems are created.

I think actually to have shown you there are common routes to so many of these different problems makes it even more important to tackle.

NEIL GOULBOURNE: Can I make a point? When exactly that argument was put to Alan Johnson in a fairly small and intimate gathering talking about health inequalities, he had been banging on like we had about things you can do on the ground in huge detail and talked about huge amounts of money the Government has put into those kinds of programmes and the point was made this will make no difference unless we deal with income inequality and that is what we should be looking at. He said well, you know, there may be plenty of evidence behind that but I just call that the Socialist Utopian argument; that is to say, never get anything right unless we get everything right. We’ve got to do something on the ground. You would entirely disagree with that. I think I do too. The Government really believes it would rather have a more Scandinavian-type society in Britain, a more equal society. It just, as you say, doesn’t feel brave enough to put that into place to do it and I think it may as well tinker on the ground in the meantime. That’s Alan Johnson’s position paper.

What I was going to ask is whether anybody disagrees with what Richard said, thinks it is important for us to talk about the things Martin expected this afternoon.

NEW SPEAKER: I don’t disagree at all. I think it’s very, very important. I’m sorry, Richard has to be a bit despondent after David Blunkett referring it back to us in terms of telling us how we can do it within the constraints of the Labour Party had to place on itself because of the electoral situation. It does get back to the earlier point about the way the agenda seems to have changed over the last month. People should be receptive to new ideas and new things. So taking Richard’s material and trying to put it in a compact form that could influence not just decision-makers, ie the Labour Party or whatever, but also with our communities the only way to start taking things forward.

MARTIN: That might mean going to local politicians and talking in the sort of terms of what are we going to do about reducing inequality of income in Bradford or wherever we are and get them to see that what they are doing is not going to have much effect unless —

NEW SPEAKER: But also — I agree with you about the giving an opportunity. My experience by the way is they say water off a duck’s back. They ignore us because the centralisation of influence and power at work within parties as well but I think the argument Alan Johnson made to you and this fear they have of the terrible defeats that the Labour Party have had in the 80s, I do think it’s part of the New Labour con trick. I don’t think the changing idealogical attitudes within society was that overwhelming that the baby had to be thrown out with the bath water. I don’t accept that. The Labour Party had their own paranoia derived largely from, or some of them very lovely, militant tendency. They got obsessed by and it caused a certain neuroses, I think — that’s the only way I can visualise it — that caused them to be absolutely set on this project and the use of a very, very, very narrow approach. One aspect of the approach that was hugely damaging, as was touched upon this morning that I have not referred to otherwise, and again will be coming apart at the seams at the moment, was their obsession with using business methodologies in the delivery of public services. I mean, one or two people talked about the commissioning environment that we are in and I think there are huge dangers there still.

As someone who has worked virtually all my life in the voluntary sector, I am all for voluntary sector organisations doing more, not ripping public sector jobs, not being a squeaky clean front for more outsourcing which is hugely damaging both to public services delivery and to the voluntary sector and its real point in life.

So I think we’ve got to kind of get people to understand that public services can’t be treated as Sainsbury’s, to use someone who is relevant, treat groceries or as manufacturers treat widgets or oil merchants treat oil. Public services are not commodities in that sense and can’t be contracted hither and thither that way.

MARTIN: Richard, tell us a bit more about the Equality Trust and the work you want to do with that.

RICHARD WILKINSON: I didn’t take the initiative for setting it up but it was set up to make the sort of material I was showing you better-known. We’re applying for some Rowntree money — that is the charitable trust not the foundation — and we’re going to launch it at same time as this book in March.

MARTIN: This is the book —

RICHARD WILKINSON: The first attempt to put down all this material in fairly straightforward language, but a lot of graphs because that feels like hard evidence and I suppose — I think what lies in front of us is a long period of building a social movement because supposing you win a marginal change in taxes or benefits, the next Government along can undo it at a stroke more easily than you can have won that change in the beginning.

So you can only get a sustained movement towards greater equality if there is a social movement in the country, political movement, behind it which means something like recreating the Socialist movement of the earlier period but that was based on an idea of nationalisation and Government control. What I suspect we need is to be using all these other forms of organisation where there is employee control of some sort or Local Authority control or mutuals or all these other forms of organisation which are not profit-making but seem to work very well indeed.

As I showed you at the beginning of the talk, it’s not economic growth we need. In fact, we’ve got to try to do without economic growth given the environmental situation. I do think there are special opportunities now. I don’t know whether people heard a few weeks ago on one of those Question Times — is it called question time with Dimbleby on the radio — David Edgar was on the panel and he said something about the Tories had been to Birmingham or Manchester?

MARTIN: Birmingham. We wouldn’t have them in Manchester.

RICHARD WILKINSON: They went to Birmingham intending to blame the poor for the broken society and ended up having to blame the rich for the broken economy. You know, those two shouldn’t obscure the fact that both of them are about inequality and there are special opportunities at the moment, people looking round for different understanding of things and, you know, there are deep worries about the broken society, if you like, where society is going with the social trends that people don’t understand and are worried by and are discussed endlessly in the media but without getting the fundamentals.

So somehow we’ve got to be the beginnings of that movement, the seeds, and we have to get it deeper than just Government policies that can be reversed. That’s why I talk about different ways or different forms of economic democracy and workplace democracy because it’s only if you get it there that you subject incomes and ownership and so on to democratic control in a way that governments can’t just put it all back to where it was before instantly.

NEW SPEAKER: Could Richard just say what he means by inequality. Are you talking mainly about income inequality or would you extend it to inequality power really and so on which might bring in some of these community involvement approaches as well which we’ve heard about.

RICHARD WILKINSON: First, we use income equality because that’s data which we can get that’s comparable. It would be very nice if you could get comparable data for inequality of assets and ownership, property and so on for different kinds.

When you mention power, think about this in terms of animal dominance hierarchies. The power, the greater power, the greater strength of the dominance the boom is what gives it control of the resources and why all these things go together so higher status greater power greater wealth all go together because they are about the same. It’s not chance that they are all together. I think we shouldn’t try and treat them as if they were separate things. It is the fact that they go together that matters, that power is used to gain privilege for self and used to express status which is intimidating to people without it.

MARTIN: I think that is a good place to stop.

RICHARD WILKINSON: Also a good place to start!

MARTIN: It is a little late on Friday afternoon to start again. We’re won’t give up on this. I mean, I think Blunkett is quite right to say “you try and find a way through this” because I don’t think anybody else is really looking and we’re as well placed as most people but it’s not going to be easy and there is — the good thing about being a Socialist Health Association is that people find inequality in health much less acceptable than inequalities in other spheres of life. No worries much — you know, was it Mandelson who was terribly relaxed about people getting filthy rich? But the idea that people in one part of – even in Kensington. Kensington is always trotted out the as healthiest pace in Britain. My friend is a councillor there. Inside Kensington there is a gap of 12 years between the wards in the north and the wards in the south where they are rich. So God knows what the life expectancy of the people in the really rich parts are. It must be immense.

People get worked up about that and that seems to me to give us a certain amount of leverage that isn’t available in other places. Half the people in this room probably make their living out of trying to do something about inequality and yes, I think most of us — I think local efforts aren’t going to produce a great deal but I don’t think we can say because we can’t do everything, therefore we should do nothing. You know, setting up exercise classes, some of the things you have been describing are certainly happening in Manchester, unfit old ladies in nastier parts of North Manchester going on walks round the town every Wednesday morning and I’ve seen them and it probably does them a bit of good because we can’t wait. Those people need something now. We can’t just leave them until we’ve sorted out the answer.

Penny Lewis: But more than that, as an unfit old lady from North Manchester, what you are doing I think is a symbol of the sort of way we want to move, aren’t they? You are actually the sort of seed corn of the sort of way we want to move in society and even — you know, even if the old lady pops off a little earlier than she’d expect, what I want is that sort of society that leaves that way of treating individuals behind really and I think it’s this change on all fronts, isn’t it? It’s not just grass roots as well but in things like academic sort of institutions, making sure these are incorporated into the syllabus. They are part of the QAA network that actually gets built in and that we actually teach the next generation.

I think also as an unfit old lady from North Manchester the current crisis has actually made me think very, very much more about how I might take a much more active role in the use of my NHS pension and that sort of thing. I think that notion of people becoming much more engaged in how their money is used on their behalf I think is a really interesting lever we can look at at the moment. I certainly will. So I think you are butterflies flapping wings in the community really.

NEW SPEAKER: The other thing about the exercise thing is the exercise in itself is good -we all know that – but actually getting a group of whatever unfit women together is a way of radicalising them and it’s a way of getting people together to talk about their particular circumstances about their health but actually it’s the anyway you can then do some of the things that Richard has said which is about going back to the origins of getting people together to talk about what sort of society they want and that’s the great — in my experience, that’s more —

NEW SPEAKER: On top of that they can start to support themselves and perhaps solve some of the problems around loneliness.

NEW SPEAKER: If they are on the streets of Manchester, then maybe they will make some demands on whatever else it is they need.

MARTIN: I hope they will.

KIERON WILLIAMS: I agree completely. The other bit I don’t want to lose before – out of all that you said, and please correct me if I have misunderstood everything you said, but the key bit for me really is this idea that actually in reducing inequalities is fundamental to improving the outcomes for the majority of society it’s not just the bottom 20% or bottom 40%, it’s the majority of people will be — the vast majority, the 90%.

RICHARD WILKINSON: Stronger than that. We no longer do economic growth, we do it by increasing equality which improves the social environment. The quality of social relations is built on material foundations and those are the scale of the material inequalities.

KIERON WILLIAMS: I think where the British debate is marginalised, a more Socialist approach by trying to imply it’s all about improving the lot of the bottom 20%, it’s not about the bigger society, but actually if what you are making a case for is improving everybody’s life, it’s an argument for everybody and isn’t such a marginalised discussion.

MARTIN: That’s what we need to talk about.

What do you think?

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