Black Report 25 years on

This conference Black Report 25 years on offered a fascinating insight into current trends in inequalities in health, and current and previous attempts to address the wider determinants of health, and reduce inequalities in health, particularly those related to income, social class, and geography.

The Chair, John Lipetz gave the conference a local context, emphasising the effects on health of factory workers during the industrial revolution.

Beverley Hughes, Minister for Children, Young People and families

gave an outline of the current situation and policies regarding health inequalities. She acknowledged there was a lot of work still to do. She wants to translate aspirational values into action, resulting in changes such as parents’ occupation is no longer being the main determinant of your health or life chances.

Presentation main points:

  • Health and healthcare is still a basic right, irrespective of income, gender, geographical location
  • Should be emphasis on quality of life as people are living longer
  • Should focus on those who need it most, as the middle classes benefit disproportionately from policy initiatives
  • Patients do not “care a jot” who provides their care – it should be provided by private companies if necessary, better value, more accessible
  • 1980s – Emphasis on individual responsibility for health
  • 1990s – social justice approach needed, inequalities persisted
  • 1997 Acheson Inquiry report. Need structural approach to address inequalities. Many recommendations not adopted.
  • Death rates have improved and narrowed, especially for certain conditions such as cancer and heart disease
  • Improvements have been made in tackling child poverty.
  • Long lead time in reducing inequalities – measures take time to reveal results eg improvements in housing leads to better health eventually.
  • “While improvements in macro socio-economic factors are important, they are not the only factors.”
  • Need lifestyle changes, improved access to better food, help to stop smoking, improved food labelling
  • Sir Michael Marmot’s report highlighted inequalities persist.
  • Need to work with local government, Sure Start, improving early years experience.
  • Target of 3500 Children’s centres by 2010.
  • Need targeted local programmes on public health eg those that stress the importance of good parenting, strategies to change behaviour, improve engagement, and reduce teen pregnancies

Questions:

how to help parents of disabled children, who are trapped in poverty. Delegate invited to write to Minister who will investigate.

Exemptions to smoke free premises will lead to widening inequalities. “We may be able to go further around smoking exemption.”

Health Living Networks, need support for older people, inter-generational and GP input

There is concern around who provides healthcare – people want good quality NHS services, not necessarily enhancing profits of private companies.

Better jobs and training needed – not necessarily better to be in work when you have low pay and poor conditions.

There should be more interagency cooperation, Minister: Don’t know why there are so many problems. Current consultation on health and social care integration, chance to people to give their views and improve interagency working.

Dr Alex Scott-Samuels, Department of Public Health, University of Liverpool

Alex’s presentation

Defined inequalities in health as:

“Unfair or unjust differences in health determinants or outcomes within or between defined populations”

Plus – there difference between equity (access to services and resources etc).

Equality – from each according to his ability, to each according to his needs.

Black Report – 25 years ago Government attempted to suppress it on publication and Health Divide report, seven years later.

1980 – As editor of Radical Community Medicine (became Critical Public Health) speaker photocopied and reproduced introduction and findings.

Black report asked are the differences

  • due to natural or social selection
  • culture & behaviour
  • structural /material inequalities?

Local reports in Sheffield at Ward level – access to health, life chances were most important

Other approaches – Psychosocial epidemiology, life course epidemiology, early life experience also valid, developed more recently.

Policy approaches

1980s – “Trickle-down” effect from rich,

Major Govt – variations in rates. Narrow focus e.g NHS

Blair I – Inequalities bad –implemented Health Action Zones, Healthy Living Centres;

Blair II – Retreat from Welfare. Neo-liberal market principles, Evidence-based e.g. “What works”, shift to right.

In capitalism – unequal distribution of resources is necessary.

Government should be honest and say what levels of inequality are acceptable

Social Democratic Model – Managed capitalism.

Health Ministers: Hazel Blears, 3 years ago. Radical speeches but little action.

Dobson, Jowell, little development

New labour is a serious threat to welfare state and public health.

Income inequalities have widened between1980 – 2003.

Inequalities in life expectancy and infant mortality have also widened

Report published 11 August 2005 – no links, mentioned at bottom of Department of Health News Release on “health trainers”, when the whole report is available on line.

Causes of death – mortality rates have decreased for many conditions, but inequalities have not reduced.

Most health policies have been “downstream” ie after people have become ill. Need upstream policies to tackle social forces such as economy.

Some are mid-downstream – e.g. Sure Start.

Choosing Health and other recent initiatives – don’t believe in universal approach, but targeting. Should be called Destroying not Choosing Health. Choosing Health dismissed as “individualistic gimmickry”.

Privatisation, commercialisation of NHS and welfare systems is continuing. Patients do care who provides their services, don’t want to contribute to profits of Evercare and other providers.

People don’t want to travel for shorter waiting lists, they want good quality local, accessible services.

Other current initiatives:

  • Choose and Book
  • Payment by Results
  • Consultations on patients-led NHS –meaningless phrase.
  • Care outside hospitals – what has happened to primary care?

See Public Money. Aug 05, 237-343.

Values. Macro –economics, global economy.

John Hewetson, 1913- 1990: Ill Health, Poverty and the State. Freedom Press. Inequalities are marked by social class. Banned in 1945:

“Achievement of full health requires a change in the system of production”.

Questions:

· But what practical solutions are there in the real world, within the capitalist system.

– Experience of GPs in Liverpool 8 – things have improved.

– Hospitals are moving older people to private nursing homes

– Need change in values, everyone should be valued. We can make incremental changes. Social democracy is a “wonderful sticking plaster for addressing wider determinants of ill-health.”

– Western countries such as Norway, and poorer countries such as Costa Rica, Cuba and the Indian state of Kerala have made significant progress, and are real welfare states.

– People should be enabled to have more control over their lives.

Keep our NHS public campaign.

Wanless economic approach not helpful – social investment state. ‘Social capital’ is a meaningless phrase.

– Need more education around health, but national health promotion bodies such as Health Education Authority abolished. No national health promotion body, whereas most European countries have these.

– A. Voluntary contributions to care not recognised by Government, at the same time seen as an excuse for rolling back state facilities. Public sector should improve community development approaches.

Professor Richard Wilkinson, Division of Epidemiology and Public Health, University of Nottingham Medical School.

Richard’s presentation

Nothing has changed in 25 years since the Black Report. The Department of Health did try and suppress the update – BBC were the only agency to pick up on the findings. The press release of 11 August 2005 did not link to the document. [Headline: Sites for first health trainers announced as report shows progress on reducing health inequalities].

The release mentions the status report, and includes a quote from Michael Marmot, one of the authors, but doesn’t link or reference it.

In fact differences in life expectancy and infant mortality between working class and middle class people have widened. This should be seen as a major abuse of human rights.

Underlying factor is income inequality, which rose sharply during the Thatcher Government, then a slight decline, then has continued steadily upwards since 1997.

There have been positive tax and benefits reforms since 1997. Reduction from one in four to one in five children in poverty.

What political action is appropriate?

What is driving health inequalities?

Psychosocial factors are important. These are the pathways through which socio-economic conditions are expressed or manifested. Eg feelings of not being valued, respected, and looked down upon. Manifests in health related behaviour such as addiction and risk of dependence, stress, worse health outcomes, violence.

International comparisons show homicide rates are higher in more unequal countries. Improvements in health will lead to reductions in violent crime and homicide.

Social gradient also influences outcomes in other areas such as education – eg Sweden and Canada have made significant progress. In the US there is less social mobility, the most significant determinant of your life chances is your parents’ (especially father’s) occupation.

Way to improve people’s health fastest is to reduce inequalities, because the higher strata are healthier anyway. Rich countries are not necessarily healthier – e.g. Greece has narrower health inequalities.

Income is a good indicator of class, manifests itself as perceived differences in status.

More egalitarian societies are healthier. Where there is more spending on health there is less perceived inequality, and narrower income distribution.

International comparisons show New Orleans has widest differences in life expectancy, and lowest health spending, and Melbourne is at the other end of the scale.

Meta analysis of 169 papers – to investigate whether there is a correlation between income and health.

  • 88 supported a significant correlation
  • 44 some correlation
  • 37 no correlation – most of these were in small areas, much deprivation within the study area, so no comparison.

“Inequality is the greater obstacle to human harmony”.

Evidence could be borne out by current situation in Iraq, and Louisiana. There is inequality in levels of violence between different states of the US. Theory that the quality of social relations, how you are perceived by other members of society, and status anxiety are all important factors here.

Differences in levels of trust, sense of community, involvement in local (or other) community all related to inequality.

Robert Puttnam has studied involvement in 20 regions of Italy, and found that there is more involvement, society is more egalitarian, and income inequalities have reduced in the last 20 years.

Violence is triggered by people feeling looked down on, disrespected, and denied access to workplace, and “markers of social respect”. More marked in materialistic societies.

Plus more social isolation affects your immune system – one experimental study showed people caught more colds the more socially isolated they were.

Psychosocial risk factors are influential throughout life

  • status, control, autonomy
  • friendships, quality of social relations
  • stress in pregnancy, low birth weight leads to later problems, early years are influential
  • insecurity and low self-esteem is influential throughout life.

Most common stressors: “Tasks that include social evaluative threats”. Jeopardy of self-esteem, regardless of your needs.

  • Reciprocity, sharing has beneficial impact on health whereas competition and the potential for conflict can have a negative effect.
  • Competition around access to resources, and status and wealth is harmful.
  • To reach equality does some people’s status need to be brought down, do the social structures need to be flattened?
  • Individual approach – train young people to handle conflict, reduce fears of inadequacy, plus reduce income differentials.
  • Need to change make-up of class structure, plus tackle interpersonal issues, and manage anger. Need to raise relative income, rather than bringing higher incomes down.
  • More employee control needed over economy. Should be more employee shareholders who form the majority at their companies.
  • Clause 4 deleted from Labour party manifesto.
  • More fragmented society, more depression. But is small scale village life the answer?
  • Less control, feelings more exaggerated in young people.
  • Collective organisation good for people, psychosocial impact.
  • Life expectancy is generally rising, but inequalities affect the rates of improvement between different groups.
  • Childhood has improved – 20-50 years ago usual treatment would be seen as abuse today.
  • Stress points in childhood and adolescence important – might be harder for middle class kids, don’t want to stand out in mixed ability
  • Involvement in struggle and collective organisation is good for health.
  • More material success but health failures – more anxiety and depression
  • Need a wider change in society that will have a direct effect on individuals

Professor John Ashton CBE, North West Regional Director Public Health

John’s presentation

Black report – Govt said it had “too many recommendations, not enough prioritising”.

Need quick wins, reports was seen as too ambitious.

Sweden adopted many of the recommendations.

There have been developments since 1997, such as Sure Start (Headstart in the US)

(Though it has been subject to criticism recently. See What Affects health – Early Life and Social Support).

Effects of inequalities are long term

  • Roots of Welfare State – empire, militarism etc
  • 30% of recruits to Boer War unfit

Post war prevention of mass unemployment, need to pay that generation back

1981 – Attempted to pass a resolution at Brighton Labour Party Conference, but told that reference to Beveridge evils – Want, Ignorance, Idleness, Squalor and Disease was old fashioned.

Previous focus was universal, but now more targeted – Population-based approach to tackling teen pregnancy, need new approach to human relations and children, rather than narrow “at risk” group approach. But at the same time perhaps you should also focus on sectors of the population who are more at risk of ill health and have worse life chances, such as children leaving care.

  • Should be focussing on Quality of life for older people – may be living longer, but in worse conditions.
  • Parts of Liverpool people have a significantly lower life expectancy than Cheshire.
  • Need more sophisticated approach to housing, and development – such as improved transport links – not just motorways through suburbs on way to town centre, but integrated networks. And communities. Little access to public transport and jobs in cities.
  • Need involvement in town planning, more citizenship.
  • Top down regeneration as evidenced by 1960s developments doesn’t work.
  • There are also wide inequalities by age and gender. Many villages in Cheshire where there are older women, widows, few younger people who have all left for cities.
  • Perinatal mortality targets to be reached by 2010. If they are not met in the North West they won’t be achieved because the rates are so high in that area.
  • There are individual risk factors, but these should be seen in the context of wider “risk conditions” eg. Working class males are six times more likely to die in accidents than middle class. – due to housing, space, traffic, supervision etc.
  • Need public health focus in Local Authorities – used to have this till 1974, where services and organisations have been split.
  • No multi agency Task Forces any more either.

Other innovative approaches include local Fire Services initiatives – increased role in accident prevention, halving deaths due to installation of fire alarms. Firefighters are working with young people, acting as role models, stations as Health Living Centres. Local Government needs more of a role in improving wellbeing.

Report by Daisy Hayden, of the Commission for Patient & Public Involvement in Health

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