Although health and life expectancy improved dramatically for everyone following the creation of the NHS, there was a strong suspicion by the 1970s that persistent health inequalities existed and that they were defined largely by social class.
There was, however, an absence of easily understood statistical evidence. In 1977, the then Health Secretary, David Ennals, commissioned the president of the Royal College of Physicians, Sir Douglas Black, to chair a working group.
Its report proved conclusively that death rates for many diseases were higher among those in the lower social classes.
By the time the Black report was published, a new Government had been elected. They displayed their enthusiasm for tackling health inequalities by publishing fewer than 300 copies of the report on an August Bank Holiday Monday in the depths of the summer recess. In his foreword to the report, the new Health Secretary could not even raise the enthusiasm to damn the report with faint praise; he simply damned it and virtually ignored it, and that remained the case for 18 years.
This is important because people assume that health has improved for everyone since the 1940s – it has, by and large – yet during those 18 years, many of the problems that Black highlighted actually got worse. For instance, in the early 1970s, the mortality rate among young men of working age in unskilled groups was almost twice as high as that among those in professional groups; by the early 1990s, it was three times as high. The most awful statistic – this began to emerge in the 1980s – was that the long-term unemployed were 35 times more likely to commit suicide than people in work.
We are also more aware today than we were then that healthcare is only part of the problem. Indeed the proportion has been calculated at between 15 and 25 per cent.
The epidemiologist Professor Sir Michael Marmot, the world’s leading expert on this subject, has established the social determinants of health. The Acheson report of the late 1990s explained: “Poverty, low wages and occupational stress, unemployment, poor housing, environmental pollution, poor education, limited access to transport, shops and the internet, crime and disorder, a lack of recreational facilities…all have an impact on people’s health.”
Beveridge’s five giants – disease, want, ignorance, squalor and idleness – were a more pithy and poetic way of describing the problem. Beveridge’s brother-in-law, the historian and Christian socialist RH Tawney, set the template that we should follow. He said the issue was “not… to cherish the romantic illusion that men are equal in character and intelligence. It is to hold that… eliminating such inequalities as have their source, not in individual differences, but in its own organisation”.
The Marmot report, which I commissioned as Health Secretary in 2008, recommended six policy areas on which we should focus: the best start in life; maximising capabilities and control; fair employment and good work; a healthy standard of living; healthy and sustainable places and communities; and a strengthened role for and provision of ill-health prevention.
The coalition Government accepted all Sir Michael’s recommendations. However, they responded with a policy – ‘Healthy Lives, Healthy People’ – in which the focus was on individual lifestyle and behavioural change. That, as Sir Michael has pointed out, is only one facet of the problem, just as the NHS is only one part of the solution. Moreover, the only piece of cross-Government co-ordinating machinery, the Cabinet Sub-Committee on health, was scrapped in 2012.
The Health Committee’s report on public health give us a fresh opportunity.
One of the Committee’s recommendations is that a Cabinet Office Minister should be given responsibility for leading on this issue. I have a more radical suggestion: the Prime Minister herself should take responsibility.
The Prime Minister is also the First Lord of the Treasury and Minister for the Civil Service, and previous Prime Ministers have taken on other ministerial positions – Churchill was Prime Minister and Defence Secretary.
It would set a wonderful example if the Prime Minister said: “I’m going to lead on this. I’m going to chair the cross-Government Committee that tackles health inequalities.”
That level of leadership is needed, because only then will there be meaningful cross-departmental work to tackle these inequalities.
Alan Johnson is the Hull West MP and a former Cabinet minister. He spoke in a Commons debate on tackling health inequality. This is an edited version.