Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health
12th September 2007 Toynbee Hall
I am delighted to give this – my first major speech as Health Secretary – here at Toynbee Hall and I’m grateful to the New Health Network for providing this opportunity.
Clem Attlee served his political apprenticeship as Secretary of Toynbee Hall, forging many of his social policies on the anvil of the terrible poverty and deprivation he witnessed in the East End.
Political leaders in his day seemed to espouse less grandiose ambitions. In 1937, Attlee wrote that the aim of socialism should be
“… to see that every family in the country has a house with electric light and power for cooking, central heating, refrigerator and plenty of floorspace… one in fact that is well furnished with everything that a modern housewife needs.”
Although he described this vision as “Utopian”, it seems positively timid when you consider the extraordinary social and economic advances in the decades that followed. Today we are enjoying wealth and health that would have been unimaginable in the 1930s – since when prosperity has increased fourfold and life expectancy has risen by more than ten years.
But although everyone is now much better off in absolute terms, inequality has flourished – as the gap between those at the top of society and those at the bottom has widened, across many areas of national life, including health.
Since the 1930s, despite the creation of the NHS, massive social reforms and unparalleled scientific advances, the gap in mortality between professional and unskilled manual men has more than doubled.
Of course, there is always a risk that, as fruits fall from the tree, it is the tallest people who catch them first and, left unchecked, this can create a dangerous political paradox: where national progress can become socially regressive, as inequality advances. It is the responsibility of progressive politicians to ensure that the benefits of change are spread equally across society.
In the period immediately after 1997, when we came into Government, we needed to repair the infrastructure in all of our public services, putting in desperately needed extra investment after decades of neglect.
Nowhere was extra cash more necessary than in health where spending has been trebled so that today there are more doctors and nurses than ever before. New hospitals are being built, mortality rates for cancer and heart disease are falling and patient satisfaction is high. The traditional “winter crisis” has been consigned to history and waiting lists are set to join them very soon.
As Sir Derek Wanless said in yesterday’s report, there have been undoubted improvements in patient care over the past five years.
But now, as we move on to the next phase of our transformation of public services, we must ensure that these improvements reach everyone, using our unprecedented investment combined with increased efficiency, to promote fairness, equality and social justice; closing the gap between rich and poor.
There can be no more chilling form of inequality than someone’s social status at birth determining the timing of their death.
The nation’s health has improved massively since the introduction of the NHS. But still a man living in Manchester is likely to die almost nine years before a man living in the Royal Borough of Kensington & Chelsea. Infant mortality amongst low skilled workers is almost twice that amongst professionals. And, for every stop on the Jubilee line between Westminster and Canning Town, life expectancy goes down by one year.
The seminal Black inquiry, commissioned under James Callaghan to examine and expose health inequalities was buried by the Thatcher Government – who published it on an August Bank Holiday with just 260 copies produced. These documents are now collectors items amongst health professionals.
In stark contrast, this Government has faced up to the problem – no matter how difficult that makes life for us politically.
In 2001, we set a target to reduce health inequalities, measured by infant mortality and life expectancy at birth, of 10% by 2010. This was a bold ambition given that, by definition, this is not an area for quick fixes, requiring as it does action across a number of departments – including education, housing and transport.
We identified the main determinants of morbidity and, on these, we have made good progress in the last few years. For instance, the number of children living in absolute poverty has halved; there has been a sharp reduction in the number of homeless families living in B&Bs; and teenage pregnancies are down by 10%.
We have also proved that, with a concerted effort, it is possible to close the gap between the affluent and the under privileged. On cardio vascular disease, the gap has closed by almost a third; on cancer, by an eighth. On infant mortality, whilst the overall trend is still poor, there has been a slight narrowing of the gap over the last year.
Life expectancy and infant mortality rates have all improved in the last decade. However, the depressing truth remains that we have not made enough progress in reducing health inequalities.
This is not a cause for donning sackcloth and ashes. After all, we were the first government in a generation to recognise this as a priority and it was us who chose to highlight the problem. Furthermore, every major, developed country in the world is struggling to resolve this dilemma – with arguably only Sweden achieving any real success. America’s life expectancy is 45th in the world, despite spending more per capita on health than any other nation.
Inequalities in healthcare mirror wider injustices in society, but we could and should be doing much more as a Department to tackle them.
We must ensure that tackling health inequalities is fully integrated into NHS commissioning and the operational framework. As R.H. Tawney wrote, promoting equality is not about some “romantic illusion that men are equal in character and intelligence” : rather, it is about eliminating the inequalities which have their source “not in individual differences, but in organisation.”
My principle objectives as Secretary of State must be two-fold: to improve the health of the whole nation, and to ensure that the health of the poorest improves the fastest.
Tackling health inequalities will be central to my Department’s work and I believe that there are a number of practical interventions that we can make to achieve success in this area. I will publish a Strategy next year setting out a bold new work programme, covering what I consider to be the two priority areas of access and prevention.
First, we must improve access to decent healthcare for people from deprived communities.
It was more than thirty years ago that the legendary Doctor Julian Tudor Hart wrote about the inverse care law: the frustrating paradox that it is those most in need of care services who are least likely to receive them. We can’t tackle inequalities in health without sorting out equal access to healthcare provision – and there remain startling disparities across the system even now.
Northumberland and Wandsworth have more than twice as many doctors per head as Barking and Dagenham, or Oldham. Oxfordshire and the New Forest perform almost twice as well on the Quality Outcomes Framework as Bradford and Bromwich.
The local GP practice is the principle gateway to the NHS: so, if the quantity, quality and accessibility of GP services are uneven, it is no wonder that health inequalities are prevalent.
There is a growing body of research from Britain and the United States demonstrating that the higher the numbers of primary care clinicians in the population, the lower the mortality rates.
But it’s more than just a numbers game.
The Healthcare Commission routinely report that people of South Asian origin view the NHS less positively than others, despite paradoxically making up a larger share of the NHS workforce.
In Tower Hamlets, a study showed that large numbers of Bangladeshi people were going straight to A&E, regardless of their ailment, because they weren’t aware of the process for going to a GP.
The more accessible primary care, the better the health of the nation, the less unnecessary burdens placed on our hospitals. Countries with weaker primary care have significantly higher healthcare costs.
The Prime Minister and I will put improvements to primary care at the forefront of our quest to improve the health of the whole nation. Next week we will be hosting a day of nationwide events on the future of the NHS across the country. I want to use these events, attended by over 1,000 patients, clinicians and members of the public, to better understand how we can improve primary care to meet the needs and aspirations of the British public in the 21st Century.
I think the key challenges are four-fold.
First, we need more doctors in the most disadvantaged areas: not just treating disease, but actively promoting better health – which I will return to later in my speech.
Second, we need doctors’ surgeries to be open at times which suit the patients rather than the practice. In a time of relative full employment, it is an anomaly that doctors’ surgeries open as the nation starts work and close when it finishes.
We should look more closely at helping people get access to GP services near their place of work as well as at home. And more patients should be able to see a GP at the weekend.
I also feel that half day closing, which survives in many practices, is a little incongruous in the 21st Century.
Third, we need to ensure that there are more routes into primary care, including high street pharmacies, sports centres and walk in centres. The greater the number of outlets, the better the chance we will deliver services at a time and place which suits the patient.
Fourth, we should ensure that more elements of the primary care workforce, including specialist nurses, physios, social care workers etc, are able to take a lead in providing care for patients.
The Next Stage review of healthcare being led by Lord Darzi is the ideal vehicle for understanding how to deliver effective treatment to local people in all strata of society and I am expecting this report to play a major role in tackling health inequalities.
We will do more to ensure that local areas have the kind of information they need to make the right decisions: including, for instance, making information on life expectancy available by geographic ward, instead of just by local authority.
We are also encouraging the most deprived parts of the country to work more closely together, sharing knowledge and experience, so we learn from what works best.
With new scientific knowledge, we hold in our hands a range of medical interventions which are as extraordinarily successful as they are deceptively simple. The greater the number of at risk patients receiving the drug statin, the lower the numbers of people dying young from heart disease. The success is due to the science. The challenge is for the administrators: making sure the system delivers the right services in the right places.
Over the next two years, we will double the number accessing smoking cessation clinics in the most deprived parts of the country. We will also increase the coverage of statin therapy for those with high cholesterol levels and hypertensives for those with high blood pressure in these areas.
But a wider transformation is needed in the way we deliver primary care.
We can only ensure that people have equal opportunities to access services if we take equal account of different people’s needs – and recognise that people’s requirements can alter, depending on race, disability, age, gender, sexual orientation and religion or beliefs.
For instance, diabetes is more prevalent amongst South Asian and Afro-Caribbean communities. Heart disease and smoking are more common amongst some South Asian communities. The suicide rate amongst men is three times that of women. And gay and bisexual men are six times more likely to have attempted suicide in their lifetime than heterosexuals. Disabled women complain that they struggle to access breast cancer screening.
We must get better at matching care to communities.
The Government’s Learning Disability Task Force has this week highlighted how people with learning disabilities face some of the greatest health inequalities.
We are currently awaiting the outcome of an independent inquiry into closing the gap for disabled people, following Mencap’s Death by Indifference report, and will feed this into our Strategy.
Another vital area is mental health. Research shows that rates of severe mental illness for some black and minority ethnic communities can be nine times higher than across the general population.
Mental health problems are the largest single cause of illness and disability in England. As the World Health Organisation says, there is “no health without mental health”.
Improving emotional wellbeing and tackling poor mental health in deprived communities is central to reducing health inequalities.
If a person’s future looks grim, and the reflection in the mirror is unappealing – based on poor self image – then smoking, drinking or over-eating can seem ever more attractive. Although these habits lead to long term problems, they can certainly provide temporary relief from boredom, frustration and distress.
Conversely, the greater people’s sense of self worth, the more they will want to take care of themselves, the likelier they are to work and contribute to society.
Research shows that access to mental health services is unequal. Asian people are less likely to be offered therapy. Black people are more likely to be compelled to take treatments.
In our manifesto, we committed to improve access to clinically proven and cost effective psychological therapies. Current provision is too patchy whilst waiting times are too long.
1 million people claim incapacity benefit because of mental health problems; and yet research shows that employment actually improves mental health.
As Richard Layard argues, if we used the £750 we pay for one month’s incapacity benefit to fund a course of talking therapies, we could help the IB recipient into a fulfilled working life.
People don’t want the life of inactivity that the system has traditionally pushed them towards. A person on Incapacity Benefit for two years is more likely to die or retire on benefits than they are to return to work.
Peter Hain and I are working together to find a new approach which can help people back to work by addressing mental health issues.
My second priority is to shift our approach from being treatment oriented to being prevention oriented, altering our focus from sickness to health.
I’m not claiming to be the first to pursue this ambition. Indeed, the 1944 White Paper, “A National Health Service”, said that, “the NHS should promote good health rather than only the treatment of bad”.
Government has often mounted massive public information campaigns, with great success: from the grainy public information broadcasts of the 40s to the dramatic, “Don’t die of ignorance” AIDS ads of the 80s.
But the imperative must be more pronounced today than ever before. As Wanless has rightly highlighted, the future of our health system depends on encouraging people to take better care of themselves. Government simply can’t afford to be the passive observers of unhealthy lifestyles, only intervening when chronic diseases such as diabetes, heart disease or lung cancer are already well established.
Public health issues must be elevated to the top of the national agenda by a Department for Health which takes an even more active role in encouraging healthy lifestyles.
Improving public health is pivotal to our assault upon health inequalities, because lifestyle differences – such as smoking, diet and exercise – are responsible for as much as half of the gap.
Many of the factors determining our health are established before we are even born.
The World Health Organisation describes birth weight as the single most important determinant in a new born baby’s survival; and there is a vast body of research to demonstrate how a baby’s weight at birth determines their health in the future.
In the short term, lower birth weight can lead to increased risk of cerebral palsy, visual impairment and deafness. In the medium term, it can slow down cognitive and physical development. In the long term, it can lead to chronic diseases such as diabetes and cardio vascular disease.
If our mantra in the 1940s was “from the cradle to the grave”, then our vision for the 21st Century should perhaps be “from the womb to the tomb”.
8% of UK babies are classed as underweight, which is less than 5.5 pounds, compared to 6.4% across Europe. Many of these babies are born in deprived communities, where the mother’s poor life choices can adversely affect the child’s life chances.
Mothers from deprived groups are over four times more likely to smoke during their pregnancy.
We need more intensive support to help pregnant mothers: not just waiting for vulnerable mothers to come to us; but with nurses and midwives going into communities to spread the message.
This approach has been pioneered in the US, with great success, and we are now developing a similar scheme aimed at disadvantaged mothers in ten deprived areas across the country.
Of course, it is not just about support: it is also about cash, which represents a very real constraint on what expectant mothers can and can not do. Research by the Nutrition Policy Panel found that the average diets of pregnant women do not meet the recommended nutritional balance, but that it is the most disadvantaged women in particular who have the lowest nutritional intake.
Even though it is an essential item, food is often one of the first areas where families will look for savings: it is one of the few outgoings, unlike rent, fuel, bills and council tax, where a struggling family can actually exercise some genuine choice and control.
By April 2009, we will introduce a new Health in Pregnancy Grant, making a payment to each expectant mother. This will be in addition to Healthy Start vouchers, worth £2.80 a week. This substantial payment will be directly linked to improving nutrition – so it will be paid alongside nutritional advice, and the sum of money will be sufficient to help every mother eat healthily during her pregnancy.
Of course, we won’t send around the food police if someone spends part of their grant on other items they may need in pregnancy. But, by supplementing valuable practical advice with necessary financial assistance, we are more likely to encourage expectant mothers to make responsible choices in a way that gives the child the best start in life.
By 2010, there will be a Sure Start Children’s Centre in every part of the country – bringing high quality healthcare along with other services to support children’s development in the early years.
The battle to improve a child’s health does not end when the child is born. As they grow, computer games and fast food will seek to draw them into a world where the only vegetable they are likely to experience is the couch potato.
Children from deprived backgrounds are four times as likely to watch television before school and twice as likely to drink sugary fizzy drinks, which is why obesity is more prevalent in these groups. But the consequences of this seemingly innocent lethargy are truly horrifying: a 20 year old who is obese can expect to lose ten years from his or her life.
When Sir David King, the Government’s Chief Scientific Adviser, publishes his Foresight report on obesity in the next few weeks, Ed Balls and I are determined to quickly develop the policies we need to respond to the challenges which the report will identify. The policy solutions we develop will depend on the spending round, but there are no shortage of practical interventions that we can make.
In the last three years, we’ve improved school food so that the share of children on the school fruit and vegetable scheme eating five fruit and veg a day has increased from just over a quarter to just under half.
The huge advances we’ve made in school sport have gone largely unnoticed by the media, but not by schools or parents. In 2004, only half of all pupils did two hours of high quality PE and sport every week. Now the figure is 80%.
We’re increasing the amount of sport children are able to do in and out of school even further. And, over the next few months, we will issue 45,000 pedometers to selected schools in deprived areas, proving that it is not just Government who will take steps to improve health in this country.
Politicians must proceed with caution when it comes to advising people on their lifestyles – avoiding a hectoring tone is crucial. At schools, we can help instill a healthy approach, but after that, it is down to personal responsibility. However, I believe that the public are now less concerned about a nanny state than they are about a neglectful state.
Take smoking – a public health success which Governments of all political persuasion can take credit for. Within a generation, we’ve gone from a situation where smoking was prevalent to one where no-one seriously disputes that public places should be smoke free.
There is more we must do. Smoking remains the biggest single cause of preventable deaths and, although we have made great progress in cutting smoking across the population as a whole, there remains a greater prevalence of smoking amongst manual workers.
What is interesting to me is that the public’s relatively sanguine response to the smoke free legislation was coupled with a widespread view that we should look more closely at alcohol consumption.
Alcohol is a more complex issue than tobacco. In moderation, it enriches our culture and enhances our life. But alcohol misuse is a menace to society and communities. Although there has been a reduction in recent years, the long term trend shows a dramatic increase in alcohol consumption, alcohol related illness and alcohol related deaths. In 1960, the French drank nearly three times as much alcohol as us. Today, we drink more than them. Every man dying from alcohol related causes loses an average 21 years from his life and a women loses 15 years. Alcohol misuse leads to a number of chronic conditions, including coronary heart disease, diabetes, stroke and cancer; it places a massive burden on GPs and local hospitals; and it is also a prime trigger of crime, disorder and violence in our communities. Nowhere does alcohol have a more destructive effect than in deprived communities, which suffer three times the number of alcohol related deaths and hospital admissions. We have a new alcohol strategy in place, but over the next few months, I want to look at whether we this can do more to tackle inequalities in alcohol consumption and harm. We will double our spend on alcohol campaigns next year, and I will make it a priority to ensure that this campaign specifically targets hard to reach deprived areas.
Health inequalities do not just occur within our nation – they exist across the world.
In Swaziland, life expectancy for women is just 37, compared to 86 in Japan. There is a similar gap between many other AIDS blighted sub Saharan states and the developed economies of the West. Unless we’re careful, the triumvirate of globalisation, climate change and urbanisation could cause these inequalities to grow. Half of the global population already live in cities but, by 2030, that could reach 60%. The Prime Minister has made a strong commitment to tackling these inequalities: combining the scientific excellence that we are fortunate to possess in this country with the global altruism that Gordon Brown has helped to lead. With the International Health Partnership, launched last week, the Prime Minister has set out his vision for conquering polio, TB, measles and then going on to address pneumonia, malaria and eventually AIDS. The G8 has committed eight billion dollars to the Global Fund, tackling malaria, TB and AIDS. We will continue to back the WHO mission on the Social Determinants of Health. I will convene a global conference on Health Inequalities, following the publication of the Commission’s report which is due in May, drawing together our knowledge and identifying clear areas for action.
In conclusion, I want to shift the focus for health: we must break the links between lack of wealth and poor health: giving everyone the chance to contribute fully to society, whether they are born in a council estate or on a country estate.
To return to Clem Attlee – his Government made the biggest contribution to tackling health inequalities by establishing the National Health Service. The NHS could never, by itself, vanquish all the injustice and unfairness in society, but it has given us a Health Service that is comprehensive, universal and free at the point of use. Now, we must utilise those advantages to improve everyone’s health, whilst improving the health of the poorest, fastest. This is the essential challenge if we wish to create “The Healthy Society”, in every sense of the word.