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Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 9 June 2008: Health Inequalities

I’d like to thank IPPR for hosting this event. Just over a year ago, as Secretary of State for Education, I spoke at an IPPR event about social mobility. Today I want to talk about the related issue of health inequalities, where evidence and the statistics are much clearer and indeed more stark.

A man living in Kensington and Chelsea will on average live ten years longer than a man living in Manchester. For all seven stops on the Jubilee line from Westminster to Canning Town, life expectancy goes down by one year. If such discrepancies were simply a matter of genetic predisposition or even bad luck, then I wouldn’t be making this speech and the IPPR wouldn’t be hosting this event.

Health inequalities reflect the need for greater equality. Poor housing, inadequate education, social exclusion and long-term unemployment all militate against good health, as poor health militates against a happy, prosperous and fulfilled life.
Victorian public health reformers such as Edwin Chadwick and Jeremy Bentham recognised over a century before the creation of a National Health Service, that squalid housing and long working hours in the dark, satanic mills of the industrial revolution led to disease and early death. Life expectancy for a factory worker in Manchester in 1848 was just 17.

But public health reforms, important though they were, could not close the yawning gap between the health of the richest and the poorest.

The creation of the NHS was undoubtedly the most important development in this battle. The introduction of universal healthcare, free at the point of need, meant that those who were unable to buy their way to good health were placed on an equal footing with those who could. The same decade saw the introduction of the other fundamental building blocks of the welfare state: the expansion of education; the most ambitious housing building programme this country has ever seen, and the creation of a modern social security system.

The determination of the post-war Labour government to address all of Beveridge’s Five Giants – Disease, Want, Ignorance, Squalor and Idleness – helped to build a society that is fairer, healthier and more prosperous for people in all social classes. Life expectancy has improved by eleven years since 1948.

The infant mortality rate has fallen from 34 out of every 1000 births to 5.
The NHS is responsible for many of the major medical advances of the last century. Cataract operations and modern techniques for hip replacements, vaccine development, gene therapy and diagnostic imaging were all pioneered by the NHS.

But while health and life expectancy improved dramatically for all, by the 70s, there was a strong suspicion that persistent health inequalities existed, defined largely by social class. There was, however, an absence of easily understood statistical evidence upon which to base a clear assertion. 

In 1977, the Labour Secretary of State David Ennals commissioned then president of the Royal College of Physicians, Sir Douglas Black, to chair a working group that would report on the extent of health inequalities in the UK and how best to address them. The report proved conclusively that death rates for many diseases were higher among those in the lower social classes.

It acknowledged that the NHS could only do so much to address the situation. It called for increases in child benefit, improvements in maternity allowances, more pre-school education, an expansion of childcare and better housing.

By this time, the Black report was published, a Conservative government had been elected, which displayed its enthusiasm for tackling health inequalities by reluctantly publishing less than 300 copies of the Black report on an August Bank Holiday Monday.

The then Secretary of State, Patrick Jenkin, did write a foreword to the report. It said, and I quote: “It will be seen that the Group has reached the view that the causes of health inequalities are so deep-rooted that only a major and wide-ranging programme of public expenditure is capable of altering the pattern. I must make it clear that additional expenditure on the scale which could result from the report’s recommendations…is quite unrealistic at present or in any foreseeable economic circumstances, quite apart from any judgement that may be formed of the effectiveness of such expenditure in dealing with the problems identified.” 
Not even deemed with faint praise It is inconceivable today that any Secretary of State could be so dismissive of an issue so critical to the life chances of so many.

For eighteen years, the issue of health inequality was largely ignored – indeed, many of its causes became more pronounced. 

Mass unemployment and cuts in essential public services saw social mobility declining in a time of rising prosperity. One in three children were being raised in poverty – the worst record of any industrialised nation.

Inequalities in health not only went unchallenged, they got progressively worse. The mortality rate among young men of working age in the early 1970s was almost twice as high in unskilled groups as for those in professional groups. But by the early 90s, this gap was three times higher.

This partly explains why one of the first acts of this government was to ask Sir Donald Acheson to revive the Black report and look once again at what we needed to do to tackle health inequality.

The programme for action that stemmed from Acheson’s report established the first ever target for reducing health inequality and an action plan to address poor health in the most deprived parts of the country. As a result, mortality rates for cancer and cardiovascular disease have fallen fastest in the most disadvantaged areas, as has infant mortality. Life expectancy has also improved significantly in those areas.

As Professor Sir Michael Marmot himself has said, in terms of approach and leadership in the international efforts to reduce health inequalities, the UK Government is a pioneer.  
But there is clearly more to do. Gaps remain, and progress is steady but it’s very slow.

The strategy for tackling health inequality that we are launching today involves action on three fronts.

First, we need to take further action on the wider determinants of health inequality. As the Black report originally pointed out, education, environment, employment, poverty and transport are all strong determinants of health and wellbeing.

Life chances are determined in the early years and indeed, even in the gestation period.
Smoking and heavy drinking during pregnancy can lead to low-birth weight babies and a greater risk of infant mortality. Low-birth weight babies are more likely to develop behavioural problems and be poor achievers in school, as well as being more susceptible to further health problems.

By the age of three, fifty per cent of our language is in place. Jim Trelease in his “Read Aloud Handbook,” quotes research by Hart and Risely in America, which shows that  a child from a deprived home will, on average, have heard 13 million words by the time they reach primary school compared to 45 million  words in a more affluent home. What starts as a lack of vocabulary can too often translate into problems with reading and writing, and eventually underachievement, which is why through Ed Balls’s Children’s Plan, the Government is expanding access to early years education and investing more in intensive support for primary school children who struggle with reading or writing.

One in twelve children live in families affected by alcohol abuse. By age 15, these children have rates of psychiatric disorder three to four times higher than their peers.

Rates of accidents amongst children and young people have fallen dramatically in recent years.

But the children of parents who have never worked or who are long-term unemployed are 13 times more likely to die from unintentional injury, and 37 times more likely to die as a result of exposure to smoke, fire or flames than the children of parents in higher managerial or professional occupations. A child in the 10 per cent most deprived wards is           3 times more likely to be hit by a car than a child  in the 10 per cent least deprived wards.
So better support for families is essential, as is affordable childcare and good quality early years education. In addition, we need to provide better and more specialised support for families facing multiple problems.

Nurse-led family partnerships show how health professionals, working with other public and voluntary services can empower first-time parents to build a secure, loving home for their children. Sure Start Children’s Centres are enjoying increasing success in providing childcare, employment services, healthcare and early years education to families who have in the past been written off under the euphemism of “difficult to reach.” Family intervention projects are providing wide-ranging support for families facing multiple problems with huge success.

We will invest and expand in all these areas over the coming years. In addition, we will do more to improve access to maternity care among vulnerable young women and ensure early identification of pregnant women and children who are at risk from health problems. We will invest more in breastfeeding promotion services. And we will set up a new, national support team to address infant mortality in those areas worst affected.

People in work have better health than those without work, and people in good jobs have the best health of all.

Long-term health problems can lead to long term unemployment. And long-term unemployment leads to poor health, in particular, poor mental health. Those who are long-term unemployed are 35 times more likely to commit suicide than those in work. Nine out of ten people claiming  incapacity benefit want and expect to return to work. But seven out of those nine are more likely to die than return to work.

Dame Carol Black set out a compelling case for improving the health and wellbeing of the working population. We will implement her recommendation by creating a new “Fit for Work” service to intervene early to prevent long term sickness that can lead to long term unemployment by helping people to return to work earlier.

In addition, we will do more to improve support for people of working age suffering from mental health conditions, which costs employers £8.4 billion each year.

More than one in six people suffer from mental health problems at any one time. But access to psychological therapies has in the past been extremely limited, despite clear evidence of its effectiveness. The natural recovery rate from depression is 20 per cent. Yet in 2000, only 9% per cent of people diagnosed with depression received psychotherapy. Last year, I announced that we would increase annual funding for psychological therapies in order to train 3,600 extra therapists. We have also funded 11 Primary Care Trusts to explore better ways of providing mental health services – in particular to support vulnerable groups such as children and adolescents.

And we will build a new partnership between employment services and NHS to help benefits claimants with substance misuse problems to get off drugs and back into work.

Healthy lifestyles.

Research shows that those who don’t smoke, exercise regularly, eat well and drink only in moderation will, on average, live 14 years longer than their less healthy peers. So our second front in this battle is to do more to promote good health.

Smoking is still this country’s biggest killer, accounting directly for 87,000 deaths a year. It is the single most powerful determinant of life expectancy.

Rising levels of obesity and the resultant increase in diabetes, cancer and heart disease could actually diminish the huge advances in medicine over the last sixty years. Nearly a quarter of adults and almost a sixth of all children are obese. If we take no action, by 2050 as the Foresight report told us, that figure will rise to over half of all adults and a quarter of all children.

The evidence shows that smoking and obesity are more prevalent in poorer parts of the country.

A poor living environment, lack of prospects and low attainment can lead people to make personal choices that damage their health.

On a very basic level, if your parents and most of your relatives smoke, then you are more likely to become a smoker yourself. If you are feeding a family of five on little more than £60 a week, it is more difficult to put healthy food on the table. If you are living in a community where there’s no access to green spaces where children can play and adults can exercise, then there’s little opportunity to stay in shape.

Promoting health and wellbeing is the raison d’être of the National Health Service, for all our citizens. But, we need to look more closely at health promotion in the most deprived communities.

We will provide extra money for smoking cessation programmes in communities where they are most needed. We will also provide better training for NHS stop smoking advisers and other healthcare professionals.

And as I announced two weeks ago, we are considering changing the regulations around how cigarettes can be marketed and sold to discourage more young people from smoking.  
Alcohol treatment programmes could have the most immediate impact on those hospital admissions caused by alcohol abuse. But access to alcohol treatment services is patchy – from 1 in 13 problem drinkers receiving treatment in London to 1 in 113 in Newcastle. As part of the strategy, we will explore how these services can be expanded.
We will also provide additional money for areas with the highest rates of alcohol-related hospital admissions to tackle problem drinking and establish a new national support team to target areas with the most alcohol-related hospital admissions.
And through the Youth Alcohol Action Plan, we will do more to tackle excessive drinking among young people.

Our strategy on obesity: Healthy Weight, Healthy Lives set out several measures to encourage people to eat healthily and exercise more - including promoting fresh fruit and vegetables and the Healthy Start scheme, which provides healthy food vouchers and vitamin supplements to low income pregnant women and families with young children.
Last Friday, we announced the Fit for the Future gym based incentive scheme targeting 10,000 16-22 year olds in five disadvantaged areas seeking to build physical activity into their lives.

Access to services

Limited access to primary care plays a major part in exacerbating health inequalities.
People in poorer areas, with lower life expectancy, have always had the least access to  to primary care. Cambridgeshire has more than twice as many doctors as Manchester, and men in Cambridgeshire will live six years longer.

People living in poorer areas are less likely to be able to book an appointment to see their GP within 48 hours and less likely to be able to see their GP at a time that’s convenient to them. They are also more likely to be dissatisfied with their local doctor.

Nothing better epitomises Doctor Julian Tudor Hart’s famous inverse care law: that those most in need of care services are least likely to receive them.
We have already set out proposals to improve access to primary care, including £250 million for those parts of the country where there are not enough doctors to procure 112 new GP practices and to enable every primary care trust in the country to develop a GP-led health centre, open from 8am in the morning to 8pm at night, 7 days a week.

The ludicrous misrepresentation of this policy by the BMA and the Conservative Party is a faint echo of their infamous double act 60 years ago when they combined to opposed the creation of the NHS itself again on absloutley spurious grounds.

This will not lead to the closure of existing GP practices, neither will we herd GPs into super-surgeries and no patient prevented from seeing their own doctor.  GP-led health centres are funded by additional investment and will provide greater capacity, particularly in areas where there are insufficient primary care facilities.
Those who oppose longer opening hours and additional investment in primary care reveal with alarming clarity their willingness to defend the narrow vested interests of the more reactionary elements of the profession, at the expense of better services for patients and in particular, better services for patients living in poorer areas.

Conclusion

In celebrating the Diamond Anniversary of the NHS, we should recognise that making medical care available for all – the weak and the vulnerable as well as the wealthy and the privileged – has made the greatest contribution to the good society that Labour  the Labour party was founded to create.

I believe society today is fairer, healthier and better educated and more prosperous than it was eleven years ago. But greater equality and the eradication of poverty must remain our guiding principles.

By promoting health and wellbeing, by strengthening our efforts to tackle the wider determinants of inequality, by making sure that everyone can access the services they need in a way that’s convenient to them, we can bridge the gap between the health of the richest and the health of the poorest.

By utilising the integrated, comprehensive health service bequeathed to us 60 years ago, we can make faster progress towards  what I believe is a noble ambition.