Black Report 10 Summary and recommendations

1. We were appointed in April 1977, at the then Secretary of State’s request, by the Department’s Chief Scientist, and with the following broad objectives:-

i. to assemble available information about the differences in health status among the social classes and about factors which might contribute to these, including relevant data from other industrial countries;

ii. to analyze this material in order to identify possible causal relationships, to examine the hypotheses that have been formulated and the testing of them, and to assess the implications for policy; and

iii. to suggest what further research should be initiated.

2.In our report we concentrate most attention upon differences in mortality rates: data on morbidity (ill-health) and on health in its more positive sense, as reflected for example in child development, are less generally available. Similarly we have had to make use largely of occupational status as an indicator of social inequality. For the majority of the population, though not for many groups at particular health risk, such as the elderly retired, this reasonably reflects such other aspects of social inequality as differences in financial resources, housing, and education. Whilst, as we will argue, such other variables may have greater importance in explaining health inequality than occupation (alone), few data permitting examination of their relationships to health are available.

3. Most recent data show marked differences in mortality rates between the occupational classes, for both sexes and at all ages. At birth and in the first month of life, twice as many babies of “unskilled manual” parents (class V) die as do babies of professional class parents (class I) and in the next 11 months 4 times as many girls and 5 times as many boys. In later childhood the ratio of deaths in class V to deaths in class I falls to 1.5-2.0, but increases again in early adult life, before falling again in middle and old age. A class gradient can be observed for most causes of death, being particularly steep in the case of diseases of the respiratory system. Available data on chronic sickness tend to parallel those on mortality. Thus selfreported rates of long-standing illness (as defined in the General Household Survey) are twice as high among unskilled manual males and 21 times as high among their wives as among the professional classes. In the case of acute sickness (short-term ill health, also as defined in the General Household Survey) the gradients are less clear.

4. The extent of the problem may be illustrated by the fact that if the mortality rate of class I had applied to classes IV and V during 1970-72 (the dates of the latest review of mortality experience) 74,000 lives of people aged under 75 would not have been lost. This estimate includes nearly 10,000 children, and 32,000 men of working age.

5. The lack of improvement, and in some respects deterioration, of the health experience of the unskilled and semi-skilled manual classes (class V and IV), relative to class I, throughout the 1960s and early 19708 is striking. Despite the decline in the rate of infant mortality (death within the first year of life) in each class, the difference in rate between the lowest classes (IV and V combined) and the highest (I and II combined) actually increased between 1959-63 and 1970-72. Among children aged 1-4 there was a small reduction in the class differential; for children aged 5-9 little or no change; for children aged 10-14 the class differential increased. Among men of economically active age there was a greater gap in mortality between class I and class V in both 1970-72 and 1959-63 than in 1949-53. For women aged 15-64 the mortality rates of classes IV and V combined actually rose between 1959-63 and 1970-72.

6. Inequalities exist also in the utilization of health services, particularly and most worryingly of the preventive services. Here, severe underutilization by the working classes is a complex resultant of under-provision in working class areas, and of costs (financial and psychological) of attendance which are not, in this case, outweighed by disruption of normal activities by sickness. In the case of GP, and hospital in-patient and out-patient attendance, the situation is less clear. Moreover it becomes more difficult to interpret such data as exist, notably because of the (as yet unresolved) problem of relating utilization to need. Broadly speaking, the evidence suggests that working class people make more use of GP services for themselves (though not for their children) than do middle class people, but that they may receive less good care. Moreover, it is possible that this extra usage does not fully reflect the true differences in need for care, as shown by mortality and morbidity figures. Similar increases in the use of hospital services, both in-patient and out-patient, with declining occupational class are found, though data are scanty, and possible explanations complex.

7. Comparison of the British experience with that of other industrial countries, on the basis of overall mortality rates, shows that British perinatal and infant mortality rates have been distinctly higher and are still somewhat higher than those of the 4 Nordic countries and of the Netherlands, and comparable with those of the Federal Republic of Germany. Adult mortality patterns, especially for men in the younger age-groups, compare reasonably with other western industralized countries: the comparison for women is less satisfactory. The rate of improvement in perinatal mortality experienced by Britain over the period since 1960 has been comparable to that of most other countries. In the case of infant mortality (which is generally held to reflect social conditions more than does perinatal mortality) all comparable countries – especially France – have shown a greater improvement than has Britain. France, like Britain and most other countries considered (though apparently not Sweden), shows significant class and regional inequalities in health experience. It is noteworthy that through the 1960s the ratio of the post-neonatal death rate (between 4 weeks and one year) in the least favoured social group to that in the most favoured fell substantially in France. Also important probably has been a major French effort to improve both attendance rates for ante-natal care and the quality of such care. Very high rates of early attendance are also characteristic of the Nordic countries; so too are high rates of attendance at child welfare clinics, combined with extensive outreach capacity. In Finland, for example, whenever an appointment at a Health Centre is missed, a health visitor makes a domiciliary call. We regard It as significant also that in Finland health authorities report not on the volume of services provided, but on the proportion of all pregnant women and of all children of appropriate ages who register with Health Centres.

8. We do not believe there to be any single and simple explanation of the complex data we have assembled. Whilst there are a number of quite distinct theoretical approaches to explanation we wish to stress the importance of differences in material conditions of life. In our view much of the evidence on social inequalities in health can be adequately understood in terms of specific features of the socio-economic environment features (such as work accidents, overcrowding, cigarette smoking) which are strongly class-related in Britain and also have clear causal significance. Other aspects of the evidence indicate the importance of the health services and particularly preventive services. Ante-natal care is probably important In preventing perinatal death, and the international evidence suggests that much can be done to improve ante-natal care and its uptake. But beyond this there is undoubtedly much which cannot be understood in terms of the impact of so specific factors, but only in terms of the more diffuse consequences of the class structure: poverty, working conditions, and deprivation in its various forms. It is this acknowledgement of the multicausal nature of health inequalities, within which inequalities in the material conditions of living loom large, which informs and structures our policy recommendations. These draw also upon another aspect of our interpretation of the evidence. We have concluded that early childhood is the period of life at which intervention could most hopefully weaken the continuing association between health and class. There is, for example, abundant evidence that inadequately treated bouts of childhood illness ‘cast long shadows forward”, as the Court Committee put it.

9.We have been able to draw upon national statistics relating to health and mortality of exceptional quality and scope, as well as upon a broad range of research studies. We have, however, been conscious of certain inadequacies in the statistics and of major lacunae in the research. For example it is extremely difficult to examine health experience and health service utilisation, in relation to income and wealth.

10. Moreover, we consider that the form of administrative statistics may both reflect and determine (as the Finnish example quoted above suggests) the way in which the adequacy and the performance of a service is understood: hence it acquires considerable importance. We also consider systematic knowledge of the use made of the various health services by different social groups to be inadequate: though this is less the case in Scotland than in England and Wales. Whilst conscious of the difficulties in collecting and reporting of occupational characteristics within the context of administrative returns, we feel that further thought must be given to how such difficulties might be overcome. We argue that the monitoring of ill-health (itself so imperfect) should evolve into a system also of monitoring health in relation to social and environmental conditions. One area in which progress could be made is in relation to the development of children, and we propose certain modifications to community health statistics.

Recommendation 1

We recommend that school health statistics should routinely provide, in relation to occupational class, the results of tests of hearing, vision. and measures of height and weight. As a first step we recommend that health authorities, in consultation with educational authorities, select a representative sample of schools in which assessments on a routine basis be initiated.

11. Accidents are not only responsible for fully one-third of child deaths, but show (with respiratory disease) the steepest of class gradients.

12. We should like to see progress towards routine collection and reporting of accidents to children indicating the circumstances, the age, and the occupational class of the parents. In relation to traffic accidents there should be better liaison between the NHS and the police, both centrally and locally.

Recommendation 2

We therefore recommend that representatives of appropriate government departments (Health and Social Security, Education and Science, Home Office, Environment, Trade, Transport as well as the NHS and the Police should consider how progress might rapidly be made in improving the information on accidents to children.

13. The Child Accident Prevention Committee, if suitably constituted and supported, might provide a suitable forum for such discussions, to be followed by appropriate action by government departments. Further,

Recommendation 3

We recommend that the Health Education Council should be provided with sufficient funds to mount child accident Prevention Programmes in conjunction with the Royal Society for the Prevention of Accidents. These Programmes should be particularly directed at local authority planners, engineers. and architects.

14. Whilst drawing attention to the importance of the National Food Survey as the major source of information on the food purchase (and hence diet) of the population, we are conscious of the scope for its improvement.

Recommendation 4

We recommend that consideration be given (drawing upon epidemiological expertise within the OPCS and elsewhere to development of the National Food Survey into a more effective instrument of nutritional surveillance in relation to health through which various at risk groups could also be identified and studied.

15. We have already referred to the difficulties in examining health experience in relation to income and wealth. In principle this can be done through the General Household Survey in which the measure of income now (since 1979) corresponds to the more satisfactory measure employed in the Family Expenditure Survey. However,

Recommendation 5

We recommend that in the General Household Survey steps should be taken (not necessarily in every year) to develop a more comprehensive measure of income, or command over resources, through either (a) a means of modifying such a measure with estimates of total wealth or at least some of the more prevalent forms of wealth. such as housing and savings or (b) the integration of income and wealth, employing a method of, for example, annuitization.

16. Beyond this, we feel that a comprehensive research strategy is needed. This is best regarded as implying the need for careful studies of a wide range of variables implicated in ill-health, in their interaction over time, and conducted in a small number of places. Such variables will necessarily include social conditions (and the interactions of a variety of social policies) as well as individual and behavioural factors. Any major advance in our understanding of the nature of health inequalities, and of the reason for their perpetuation, will require complex research of a multidisciplinary kind.

Recommendation 6

The importance of the problem of social inequalities in health. and their causes. as an area for further research needs to be emphasized. We recommend that it be adopted as a research priority by the DHSS and that steps be taken to enlist the expertise of the Medical Research Council as well as the Social Science Research Council, in the initiation of a programme of research. Such research represents a particularly appropriate area for Departmental commission of research from the MRC.

17. We turn now to our recommendations for policy, which we have divided into those relating to the health and personal social services, and those relating to a range of other social policies. Three objectives underpin our recommendations, and we recommend their adoption by the Secretary of State

1. To give children a better start in life.

2. To encourage good health among a larger proportion of the population by preventive and educational action.

3. For disabled people, to reduce the risks of early death, to improve the quality of life whether in the community or in institutions, and as far as possible to reduce the need for the latter.

Thirty years of the Welfare State and of the National Health Service have achieved little in reducing social inequalities in health. But we believe that if these 3 objectives are pursued vigorously inequalities in health can now be reduced.

18. We believe that allocation of resources should be based on need. We recognise that there are difficulties in assessing need, but we agree that standardised mortality ratios (SMRs) are a useful basis for broad allocation at regional level. At district level, further indicators of health care and social needs are called for. These should be developed as a matter of urgency, and used appropriate1y to reinforce, supplement or modify allocation according to SMRs. However, a shift of resources is not enough: it must be combined with an imaginative (and in part necessari1y experimental) approach to health care and its delivery.

Recommendation 7

Resources within the National Health Service and the Personal Social Services should be shifted more sharply than so far accomplished towards community care particularly towards ante-natal, postnatal and child health services, and home help and nursing services for disabled people. We see this as an important part of a strategy to break the links between social class or poverty and health.

Recommendation 8

The professional associations as well as the Secretary of State and the Health Authorities should accept responsibility for making improvements in the quality and geographical coverage of general practice. especially in areas of high prevalence of ill-health and poor social conditions. Where the number or scope of work of general practitioners is inadequate in such areas we recommend Health Authorities to deploy or redeploy an above-average number of community nurses attached where possible to family practice. The distribution of general practitioners should be related not only to population but to medical need. as indicated by SMRs supplemented by other indicators, and the per-capita basis of remuneration should be modified accordingly.

19. Moreover we consider that greater integration between the planning process (and the establishment of priorities) and resource allocation is needed. In particular, the establishment of revenue targets should be based not upon the current distribution of expenditure between services, but that distribution which it is sought to bring about through planning guidelines: including a greater share for community health.

Recommendation 9

We recommend that the resources to be allocated should be based upon the future planned share for different services including a higher share for community health.

20. Our further health service-related recommendations, designed to implement the 3 objectives set out above, fall into 2 groups.

21.We first outline the elements of what we have called a District Action Programme. By this we mean a general programme for the health and personal social services to be adopted nationwide, and involving necessary modifications to the structure of care.

22. Second, we recommend an experimental programme, involving provision of certain services on an experimental basis in 10 areas of particularly high mortality and adverse social conditions, and for which special funds are sought.

District Action Programme

Health and Welfare of mothers- and preschool and schoolchildren

Recommendation 10

A non-means-tested scheme for free milk should now be introduced beginning with couples with their first infant child and infant children in large families.

Recommendation 11

Areas and districts should review the accessibility and facilities of all ante-natal and child health clinics in their areas and take steps to increase utilisation by mothers, particularly in the early months of pregnancy.

Recommendation 12

Savings from the current decline in the school population should be used to finance new services for children under 5. A statutory obligation should be placed on local authorities to ensure adequate day-care in their area for children under 5 and a minimum number of places the number being raised after regular intervals should be laid down centrally. Further steps should be taken to reorganise day nurseries and nursery schools so that both meet the needs of children for education and care.

Recommendation 13

Every opportunity should be taken to link revitalised school health care with general practice and intensify surveillance and follow up both in areas of special need and for certain types of family.

23. Some necessary developments apply to other groups as well as children and mothers.

Recommendation 14

An. assessment which determines severity of disablement should be adopted as a guide to health and personal social service priorities of the individual. and this should be related to the limitation of activities rather than loss of faculty or type of handicap

24. Though we attach priority to the implementation of this recommendation in the care of disabled children, we believe that it must ultimately apply to all disabled people. We recognise that such assessments are now an acknowledged part of “good practice” in providing for the disabled – we are anxious that they should become standard practice.

The care of Elderly and Disabled people in their own homes

25. The meaning of community care should be clarified and much greater emphasis given to tendencies favoured (but insufficiently specified) in recent government planning documents. ( See Recommendation 7).

Recommendation 15

A Working Group should be set up to consider:

i. the Present functions and structure of hospital residential and domiciliary care for the disabled elderly in relation to their needs in order to determine the best and most economical balance of future services; and

ii. whether sheltered housing should be a responsibility of social services or of housing departments and to make recommendations;

Recommendation 16

Joint funding should be developed and further funding of a more specific kind should be introduced if necessary within the exist the existing NHS budget, to encourage joint care programmes. A further sum should be reserved for payment to authorities putting forward joint programmes to give continuing care to disabled people – for example post-hospital follow-up schemes, pre-hospital support schemes for families. and support programmes for the severely incapacitated and terminally ill.

Recommendation 17

Criteria for admission to or continuing residence in residential care should be agreed between the DHSS and the local authority associations, and steps taken to encourage rehabilitation. and in particular to Prevent homeless elderly people from being offered accommodation only in residential homes. Priority should be given to expansion of domiciliary care for those who are severely disabled in their own homes.

Recommendation 18

The functions of home helps should be extended to permit a lot more work on behalf of disabled people; short courses of training, specialisation of functions and the availability of mini-bus transport, especially to day centres. should be encouraged.

Prevention: the role of Government

26. Effective prevention requires not only individual initiative but a real commitment by DHSS and other government departments. Our analysis has shown the many ways in which people’s behaviour is constrained by structural and environmental factors over which they have no control. Physical recreation, for example, is hardly possible in inner city areas unless steps are taken to ensure that facilities are provided. Similarly, government initiatives are required in relation to diet and to the consumption of alcohol. Legislation and fiscal and other financial measures may be required and a wide range of social and economic policies involved. We see the time as now opportune for a major step forwards in the field of Health and Prevention.

Recommendation 19

National health goals should be established and stated by government after wide consultation and debate. Measures that might encourage the desirable changes in people’s diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies.

Recommendation 20

An enlarged programme of health education should be sponsored by the Government. and necessary arrangements made for optimal use of the mass media. especially television. Health education in schools should become the joint responsibility of LEAs and health authorities.

27. The following recommendation should be seen not only as a priority in itself but as illustrative of the determined action by government necessary in relation to many elements of a strategy for prevention:

Recommendation 21

Stronger measures should be adopted to reduce cigarette smoking

These would include:

a. legislation rapidly to phase out all advertising of tobacco products (except at place of purchase);

b. sponsorship of sporting and artistic activities by tobacco companies should be banned over a period of a few years. and meanwhile there should be stricter control of advertisement through sponsorship;

c. regular annual increases in duty on cigarettes in line with rises in income should be imposed to ensure lower consumption;

d. tobacco companies should be required to submit plans in consultation with Trades Unions for the diversification of their products over a period of 10 years with a view to the eventual phasing out of sales of harmful tobacco products at home and abroad;

e. a stronger well presented warning should appear on all cigarette-packets and such advertisements as remain. together with information on the harmful constituents of’ cigarettes;

f. the provision of non-smoking areas in public places should steadily be extended, and

g. a counseling service should be made available in all health districts. and experiment encouraged in methods to help people reduce cigarette smoking.

We have already recommended that steps be taken to increase utilisation of ante-natal clinics, particularly in the early months of pregnancy (Recommendation 11). Given early attendance there are practical programmes for screening for Down’s Syndrome and for neural tube defects in the fetus. In relation to adult disease, screening for severe hypertension is practicable, and effective treatment is available.

Recommendation 22

In the 1ight of the present state of knowledge we recommend that screening for neural tube defects (especially in high risk areas) and Down’s Syndrome on the one hand, and for severe hypertension in adults on the other should be made generally available.

Additional Funding for 10 Special Areas

Recommendation 23

We recommend that the Government should finance a special health and social development programme in a small number of selected areas, costing about £30m in 1981-82.

28. At least £2m of this sum should be reserved for evaluation research and statistical and information units. The object would be both to provide special help to redress the undeniable disadvantages of people living in those areas but also to permit special experiments to reduce ill-health and mortality, and provide better support for disabled people. Some elements of such a programme are illustrated, particularly in connection with the development of more effective ante-natal services.

Measures to be Taken Outside the Health Services

29. In discussing actions outside the Health Care system which need to be taken to diminish inequalities of health we have been necessarily selective. We have attempted to pay heed to those factors which are correlated with the degree of inequalities. Secondly, we have tried to confine ourselves to matters which are praoticab1e now, in political, economic and administrative terms, and which will nonetheless, properly maintained, exert a long-term structural effect. Third, we have continued to feel it right to give priority to young children and mothers, disabled people, and measures concerned with prevention.

30. Above all, we consider that the abolition of child poverty should be adopted as a national goal for the 1980s. We recognise that this requires a redistribution of financial resources far beyond anything achieved by past programmes, and is likely to be very costly. Recommendations 24-27 are presented as a modest first step which might be taken towards this objective.

Recommendation 24

As an immediate goal the level of child benefit should be increased to 5½% of average gross male earnings or £5.70 at November 1979 prices.

Recommendation 25

Larger child benefits should be progressively introduced. for older children after further examination of the needs of children and consideration of the practice in some other countries.

Recommendation 26

The maternity grant should be increased to £100.

Recommendation 27

An infant care allowance should be introduced over a 5 year period beginning with all babies born in a year following a date to be chosen by the government.

31. Beyond these initial elements of an anti-poverty strategy, a number of other steps need to be taken. These include steps to reduce accidents to children, to which we have referred above (Recommendation 4). Further,

Recommendation 28

Provision of meals at school should be regarded as a right. Representatives of local authorities and community dieticians should be invited to meet representatives of parents and teachers of particular schools at regular intervals during the year to seek agreement to the provision and quality of meals. Meals in schools should be provided without charge.

Recommendation 29

A comprehensive disablement allowance for people of all ages should be introduced by stages at the earliest possible date beginning with people with 100 per cent disablement.

Recommendation 30

Representatives of the DHSS and DE, HSE, together with representatives of the Trade Unions and CBI should draw up minimally acceptable and desirable conditions of work.

Recommendation 31

Government Departments, employers and unions should devote more attention to preventive health through work organisation, conditions and amenities. and in other ways. There should be a similar shift of emphasis in the work and functions of the Health and Safety Commission and Executive and the Employment Medical Advisory Service.

Recommendation 32

Local Authority spending on housing improvements under the 1974 Housing Act should be substantially increased

Recommendation 33

Local authorities should increasingly be encouraged to widen their responsibilities to provide for all types of housing need which arise in their localities.

Recommendation 34

Policies directed towards the public and private sectors need to be better coordinated.

Recommendation 35

Special funding on the lines of joint funding for health and 1oca1 authorities should be developed by the Government to encourage better Planning and management of housing, including adaptations and provision of necessary facilities and services for disabled people of all ages by social services and housing departments.

32. Our recommendations reflect the fact that reduction in health inequalities depends upon contributions from within many policy areas, and necessarily involves a number of government departments. Our objectives will be achieved if each department makes its appropriate contribution. This in turn requires a greater degree of co-ordination than exists at present.

Recommendation 36

Greater co-ordination between Government Departments in the administration of health related Policies is required t by establishing inter-departmental machinery in the Cabinet Office under a Cabinet sub-committee along the lines of that established under the Joint Approach to Social Policy with the Central Policy Review staff also involved. Local counterparts of national coordinating bodies also need to be established.

Recommendation 37

A Health Development Council should be established with an independent membership to play a key advisory and planning role in relation to a collaborative national po1ioy to reduce inequalities in health.

33. Within such coordinating machinery major initiatory responsibility will be vested in the Department of Health and Social Security, and we recommend that the Cabinet Committees we have proposed be chaired by a Minister, and by a senior DHSS official respectively, having major responsibility for Health and Prevention. Similarly it will be an important obligation upon the DHSS to ensure the effective operation of the Health Development Council.

Notes on what happened to these recommendations