Black Report 9 Policies to reduce Health Inequalities:2 a Wider Strategy

9.1 In Chapter 6 we showed that people’s associations, and mutual expectations at work, in the home and family, in the neighbourhood and community, and in other organisational or social roles, are continually evolving, and that marked differences in the material base or context of their associations substantially explain inequalities in their health and well-being.

9.2 Whilst the health care services can play, and do play, a significant part in reducing inequalities in health, yet measures to reduce differences in material standards of living as experienced at work, in the home and in everyday social and community life axe of even greater importance. We have in mind not simply a general reduction in inequalities in living standards but particularly a relative improvement of the living standards of certain groups of poor people, including families with children, together with measures to prevent new structures and technologies from undermining the existing living standards of some groups. Like the strategy we outlined for the health care system in Chapter 8 the strategy which deserves to be adopted outside that system needs to be comprehensive and interlinked rather than fragmentary. Among the policies which are then pursued certain priorities to help groups of poor people and prevent new forms of deprivation from arising must be selected. Efforts therefore have to be made both to identify key elements and integrate them into a concerted whole. We will outline how a broad strategy might then be made up and make certain specific proposals for inclusion in it. Thus we will first outline the general need for an anti-poverty strategy, and then discuss and recommend selected measures – especially for families with children and disabled people.

A Comprehensive Anti-poverty strategy

9.3 Despite increases in GNP during the 1960s and 1970s successive Governments have recognised the wide extent of poverty in the United Kingdom. In 1966 the Report of a Government survey of retirement pensioners estimated that up to 750,000 elderly people were living below national assistance standards most of whom were eligible to draw national assistance and were not claiming it (Ministry of Pensions and National Insurance, 1966, p.20). In 1967 a further report on a survey of families with children estimated that there were 160,000 families with half a million children who were living under the new Supplementary Benefit scale rates (Ministry of Social Security, 1967, P. iv). Further reports from the DHSS in the early 1970s tended to confirm the large numbers of people with incomes below the scale rates and yet who were in, or they were dependants of people who were in, full-time employment. (See for example, Howe, DHSS, 1971). In Table 6.2 we showed, on the basis of DHSS estimates, that in 1977 over 14 million people (or 26.6% of the population) had incomes of not more than 40% above the supplementary benefit level. About a third were employed, or were dependants of people who are employed, and about two-fifths were retirement pensioners. (Because of under-representation of elderly and sick and disabled people the use of a measure of “normal” instead of “current” income for people who have been sick or unemployed for less than 3 months, and the exclusion of those receiving supplementary benefit from the data, numbers with incomes below SB level are underestimated (Townsend, 1979 pp. 275-276 and 908-909).) At these levels of income there is evidence of multiple deprivation in diet, housing and environmental amenities, leisure activities and at work. Because of changes in earnings and numbers of dependants the movement of people into and out of poverty is considerable, and while there is no hard evidence for a long span of individual life it may be inferred, from (i) survey of cross-sectional data, (ii) data about incomes currently and for the previous year, and (iii) New Earnings Survey data followed through for several years, that a very high proportion of manual workers experience poverty, or exceptionally low living standards, for a substantial part of the life-cycle.

9.4 There are differences of view about what in fact constitutes poverty. The main question is how far a definition acceptable to government should depend on need, as assessed in contemporary society and how far on needs as measured by some historical bench-mark. Today’s poor in Britain have more purchasing power than the poor of the depression years of the 1930s because of the growth of national prosperity. But they are living in a different kind of society, in which they have and are held to have different obligations as workers, parents, householders, friends and citizens. We therefore take the view that any historical standard of need becomes more and more unreal with the passage of time in a changing and especially growing economy even when it is repriced in accordance with rises in the cost of living. An effort has to be made very few years to redefine the standard itself in accordance with changing social conditions. As long ago as 1812 Adam Smith recognised this for consumer goods in declaring that “by necessities I understand, not only the commodities which are indispensably necessary for the support of life, but whatever the custom of the country renders it indecent for creditable people even of the lowest order to be without”. The latest report of the Supplementary Benefits Commission (Annual Report for 1978, 1979) expresses the point as follows: “Poverty in urban industrial countries like Britain is a standard of living so low that it excludes and isolates people from the rest of the community. To keep out of poverty they must have an income which enables them to participate in the life of the Community.”

9.5 In our view the structural dimension is of as much, if not greater, importance than the historical dimension in explaining why inequalities in health exist and how they are perpetuated. What is undeniable is the huge difference between some non-manual occupations and certain manual occupations in mortality and morbidity, and the corresponding difference in material amenities at work and outside work, which are both reflected in, and determined by, the allocation of resources.

9.6 A comprehensive anti-poverty strategy must therefore fall into two parts. One is a fairer distribution of resources. While measures have to be taken to increase the living standards of poor people relative to those who are better off we believe that post-war history shows the inadequacy of the approach to this problem which has been followed by successive governments. Following the Beveridge philosophy of the war years it was supposed that the state did not so much have to intervene in the initial production and determination of the structures of wealth and of gross incomes in the first place, as develop the taxation of some forms of gross incomes once received or determined, so that minimum subsistence incomes for the poor could be financed. High rates of taxation had been introduced in the war. The problem was that after the war steps were taken on behalf of those principally affected to reduce the impact of progressive taxation both by inflating gross incomes and substituting fringe benefits in kind – which escape tax altogether or attract a lower rate of tax. Moreover, the number of dependent poor for whom taxes (or the equivalent in national insurance contributions ) had to be raised was rapidly increasing.

9,7 Thus, the aim of different political parties in Britain to raise the relative living standards of the poor was largely frustrated by growing opposition to progressive taxation (as well as diminution of its practical effects) and by the steady growth relative to the employed population of the dependent population. Different examples might be given of this growth. Between 1951 and 1976 the number of social security beneficiaries (excluding those receiving family allowances) grew from just over 7.5m to 14.25m, or by 88 per cent, while the total population increased from 51m to 56m or by only 10 per cent (Social Trends. 1979. Pp. 32 and 116). The Government expects the number of social security beneficiaries to grow to over 15.5m by 1982-3, even on an assumption of no growth in unemployment (Cmnd. 7439, P. 151).

9.8 In effect governments tried to meet this developing problem by lowering the tax threshold and shifting the balance from direct to indirect taxation. They also tried to reduce the growing costs of categories already defined as dependent, as well as meet the additional costs of new categories whose needs came to be recognised publicly, by relying increasingly on the supplementary benefit and other means-tested schemes.

9.9 But the post-war consensus about the entitlements of the poor and the methods of financing their incomes appears to have reached a dead end. In the 1980s either the living standards of the poor will not be maintained relative to the rest of the population as their numbers grow, or if living standards are maintained or efforts are made even to improve them, then radically new methods of financing them from the prosperous sections of the population have to be devised.

9.10 We believe that a new approach to the fairer distribution of resources needs to be developed on the following basis. The dispersion of resources is in fact very unequal, and the long-term objective of reducing by a moderate amount the proportionate share of, say, the top 30 per cent of income recipients, would substantially augment the sum redistributed at present to the poor. (If the shares of disposable income of the top 30% as given in Report No 5 (P.75) of the Royal Commission on the Distribution of Income and Wealth, were only moderately reduced after a programme of new measures, the sum available for distribution in social security benefits, for example, could be doubled.) Though the political task will be difficult, greater restriction on the amout of wealth which may be inherited and accumulated, together with more effective measures to inhibit the growth of top incomes and reduce present differentials in incomes, preferably within the framework of nationally agreed and statutorily enforced maximum and minimum incomes, with appropriate adjustments for dependencies will need to be developed. Quite what form this might take, and how it might be democratically agreed and enforced, is not something which it is possible to develop in these pages. However, we believe that pride of place in a comprehensive anti-poverty strategy must be given to the greater equalisation of wealth and of other resources, with the possibility of defining national minimum and maximum earnings (and family income) as indispensable elements of a nationally approved framework of incomes. Within statutory limits local and industrial or occupational wage-levels might be negotiated. Below we will recommend certain measures to be included in such a strategy.

9.11 The second part of a comprehensive anti-poverty strategy is to encourage self-dependence and a high level of individual skill and autonomy as a basis for creating a more integrated society. We believe that this is possible only by raising the standards and broadening the content of education so that the need for advice or supervision from professionally trained personnel in medicine, nursing, law, housing, child care or administration is less marked or frequent and the capacity to undertake a range of skills greater; by improving individual access to information about, and control over what goes on in the immediate community as well as society generally; and by conferring rights to employment and occupation and creating corresponding opportunities for such employment. There are of course possibilities of augmenting formal education as, for example, Halsey and others have shown in pre-school teaching schemes (Halsey, 1980) and of introducing into the curriculum more studies of such subjects as health and nutrition, and (some believe) political education. Methods of enabling adults to have better access to knowledge, theoretical and practical, are equally important.

9.12 Britain has an honourable history in the development of local voluntary organisations. There are many good modern reasons, (including community profit from technological advances) for vigorous support and encouragement of local community associations and groups – especially those run by their membership.

9.13 Access to fulfilling employment or occupation is the most important of the rights which are necessary to promote the principle of self-help. Among a variety of possible measures there are two which deserve special mention. One is the energetic sponsorship of new industrial enterprise, based upon newly emerging technologies. In face of a world recession in world trade and severe foreign competition the nation cannot afford to be timid. The other measure is to expand employment within different branches of community service. Up to the present time the youth opportunities programme and similar schemes have done little more than provide some people who would otherwise count as unemployed with temporary, and ill-paid, employment. There are thousands of other men and women who have been unemployed for many months and whom it costs the state nearly as much to support as it would if they were employed in different kinds of service to raise the quality of life for elderly and disabled people.

9.14 This is necessarily an abbreviated outline of a possible strategy, and yet it is within such an outline that a number of specific measures deserve to be picked out and explained as priorities for the Government to consider. In the rest of this Chapter we will develop certain priorities outside the health care systems which correspond with the same objectives to which our recommendations for the health service were directed.

9.15 The major thrust of the strategy to be outlined in this Chapter is towards families and children. Top priority must be given to measures which will enhance family living standards and reduce the high risk of children suffering those forms of deprivation and poverty which inhibit health development In drawing this conclusion we are conscious in particular of two facts of the utmost importance:-

i.There is evidence of substantial deprivation among young children (for example, Wilson and Herbert, 1978; Bone, 1977) and, after people of advanced age, they run the highest risk of all age-groups of being in poverty (Townsend, 1979, p. 285);

ii. Those in middle and late middle life (mostly couples without dependants) have a standard of living, measured in relation to supplementary benefit scales rates, far higher than that of families in which there are young children (loc cit, 1979, Figure 7.1 p. 288). This difference between the young and the middle aged appears to have grown more marked in recent years, partly because the rearing of children has been completed after the first 20 or 25 years of adult life by more married couples in each succeeding cohort, but partly because more married women have reentered employment, non-manual occupations with strongly defined incremental pay scales have grown disproportionately, and more of the middle aged have had access to cheap housing – through the completion of mortgage repayments or a relative fall in the real value of repayments, because of inflation. The implication for policy is therefore both that a need exists to direct more resources towards children and that checks might be placed on the tendencies for people in middle life without dependants to attract an undue share of additional national resources – so that adequate measures for young children might with less difficulty be financed. A complex programme covering financial well-being, education, nutrition and housing must be developed. In this chapter we have selected some principal measures to give effect to such a programme.


9.16 It is our view 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. We recognise also that with the growth in national income it will become easier to find the resources for such an anti-poverty strategy. The recommendations which we make below are presented as a modest first step which might now be taken towards such an objective.


9.17 The history of child benefit has proceeded through 2 stages and is now entering a third. The first was the campaign to establish family allowances culminating in the Family Allowances Act 1945. History demonstrates the different motives of the participants in the campaign. “Family allowances were supported in the early days as a means of reducing inequalities between rich and poor, and between men and women. To socialists and feminists these were worthy ends in themselves but were not regarded as legitimate ends for government social policy until the Second World War. Broader support from Liberals and Conservatives was forthcoming only when family allowances became linked with other problems: a declining birth rate, poverty and malnutrition among children, the maintenance of work incentives, and the need to curb inflation. These problems were established concerns of government and thus, by association, the legitimacy of family allowances was enhanced”. (Land H., 1975, p.227). But although the functions of family allowances were differently regarded, the government had finally accepted the principle that “society should include in its economic structure some form of direct financial provision for the maintenance of children, instead of proceeding on the assumption that, save in cases of exceptional misfortune, this is a matter which concerns only individual parents and should be left to them because normally men’s wages or salaries are, or ought to be and can be made to be, sufficient for the support of their families”. (Rathbone, E, 1940, p.xi). The government paid 25p (less than the 40p recommended by Beveridge) per week for every dependent child excluding the first. This amount compared with 52 1/2 p for each child, including the first, which was paid as an allowance to the wives of men in the armed forces at the time. The total cost of these “separation” allowances for children was approximately £80m compared with the cost of £57m in the first year of family allowances (Land, E. 1975, p.215).

9.18 The second stage in the evolution of universal cash allowances for children was the eventual re-kindling of a campaign to extend family allowance to the first child in the family and simultaneously increase the real value of all family allowances, partly in exchange for the phasing out of child tax allowances. This stage culminated not so much in the Child Benefit Act of 1975 as the completion of its phasing-in during the 2 years from April 1977 up to the Budget of 1979. What were the important developments during this period? In the previous 3 decades government support for family allowances had flagged. For example, between 1946 and 1978 pensions and other major social security benefits were increased on 17 occasions, whereas family allowances were increased only 6 times. In the late 1960s and 1970’s evidence of poverty among the families of wage-earners was widely discussed (Abel-Smith, B, and Townsend, P. 1965). Scandinavian, EEC and Eastern European countries had introduced children’s allowance schemes which were more generous, relatively to average earnings and GNP. For example, in 1975 the UK coverage of children through its family allowance programme was the lowest of the 9 EEC countries and its expenditure on family benefits as a percentage of GNP not only the lowest but less than half the average percentage of the other 8 countries. (EEC , Report on the Development of the Social Situation in the Community in 1976, 1977, pp 222-225). Britain’s poor record in family benefits over a considerable span of years must be linked not only to the relatively large numbers of wage-earning families found in national and international surveys to be living in poverty or on its margins (Ministry of Social Security 1967; DHSS analyses of family poverty 1974-76) but the failure of infant mortality rates to decline as rapidly as those of some other countries (Chapter,5, p122). Again, inflation in the last 15 years has tended to hit the poorest hardest (see, for example, the evidence by Professor J Nuellbauer, The National Consumer Council, David Piachaud, and the Low Pay Unit in Royal Commission on the Distribution of Income and Wealth, 1978. Though see Department of Employment Gazette February 1979, March 1979, for a contrary view).

Table 9.1 Change in value of tax threshold 1955-6 to 1977-8

Year Value of allowance at current prices Value of allowance at constant prices
Single Married
Married plus
Single Married
Married plus
2 children 11-16 3 children 11-16 2 children 11-16 3 children 11-16
1955-6 180 309 566 694 100 100 100 100
1966-7 283 437 797 977 112 101 100 100
1968-9 283 437 751 885 104 94 87 84
1970-1 418 598 904 1030 136 113 93 87
1972-3 591 771 1180 1358 165 125 104 98
1974-5 625 865 1363 1586 134 108 92 88
1975-6 675 955 1453 1676 116 96 79 74
1976-7 735 1085 1703 1986 109 94 80 76
1977-8 945 1455 1891 2096

Source: Royal Commission on the Distribution of Income and Wealth, report no 6 CMD 7175

9.19 The factors summarised above were among the ingredients determining the relativities of living standards and lay behind an increasingly tempestuous debate about government family policy in the late 1960s and early 1970s.

9.20 By 1976 the rate of family allowance was £1.50, paid for each child after the first, and on which tax was paid. However, because of the effects of “clawback” introduced in 1967-8 at the time of a previous increase in family allowances this was worth only 62 1/2 p to the great majority of families paying tax at the standard rate. Additionally, there was tax relief for each child of £300, £335 or £365 according to age. This was equivalent to £2.02, £2.05 and £2.46 a week respectively to a parent paying tax at the standard rate. Tax relief was worth a lot more to families with high incomes paying tax at the higher rates. The continued fall in tax thresholds and the consequent application of “clawback” to low income families meant that fewer and fewer families benefitted.

9.21 As part of their tax credit scheme foreshadowed in the budget of 1972 and illustrated in a Green Paper in October 1972 (Cmnd 5116, 1972), the Conservative administration proposed to abolish these 2 forms of allowance and pool the money in a child “credit” for each child in the family. The Labour Party had been developing a “Child Endowment” scheme (Labour’s Programme. 1973, p 71). So far as children were concerned, a Parliamentary Select Committee on tax credit helped to resolve some of the differences between the parties. It agreed unanimously to recommend that child credit should be paid to the mother and should be “a cash payment on a universal basis through the Post Office”. This represented an important change in the principle of tax credits.

11.22 After the election of 1974 the proposal had a chequered history right up to the point when a benefit of £1 per week for the first child was introduced in April 1977. This still meant that the level of child support (including the residual value of child tax allowances) remain below that even for the late 1960s, as Table 9.2 shows. In purchasing value the support for families with more than one child represented a lower value than available even in 1946 (Hansard, 1 February 1979, cols 525-6) but in April 1976 the rate of child benefit was increased to £2.30 for each child, in November 1978 to £3 and in April 1979 to £4 per child. The completion of these phases can be said to mark the close of the second stage of the history of child support. (For a detailed account of the recent history, see The Great Child Benefit Robbery, April 1977; Iand, E. 1978; Field, F. February 1978; and Field, F. September 1978).

Table 9.2 Value of Family Support to standard rate tax payer as a percentage of average gross and net income

Year Value of child tax allowances and family allowances/child benefits as a percentage of gross income for Value of child tax allowances and family allowances/child benefits as a percentage of gross income for
1 child family % 2 child family % 4 child family % 1 child family % 2 child family % 4 child family %
Oct 1964 4.7 10.8 22.6 5.5 11.9 23.8
Oct 1965 4.6 10.5 21.9 5.5 11.8 23.3
Oct 1968 4.0 9.0 18.4 4.8 10.8 21.2
Oct 1969 3.7 8.2 16.7 4.5 9.9 19.5
Apr 1970 3.4 7.7 15.8 4.3 9.5 18.8
Apr 1970 3.1 6.9 14.2 3.9 8.6 17.2
Apr 1971 3.5 7.8 15.9 4.5 9.6 18.7
Apr 1972 3.2 7.0 14.4 4.0 8.6 16.9
Apr 1973 2.7 6.1 12.5 3.5 7.6 15.2
Apr 1974 3.2 6.8 13.9 4.2 8.7 16.9
Apr 1975 2.7 6.2 12.8 3.7 8.3 16.4
Apr 1976 2.8 6.4 13.0 3.9 8.6 16.6
Apr 1977 2.9 6.0 12.0 3.9 7.9 15.1
Apr 1978 3.2 6.3 11.9 4.3 8.3 15.3
Nov 1978 3.7 7.2 13.9 5.0 9.6 18.1
Apr 1979 3.8 7.3 13.6 5.0 9.6 17.4

9.23 The current rates of child benefit do not yet represent levels sufficient to ward off poverty, equalise living standards between families with and without dependants, and lay the basis for meeting a child’s immediate needs in modern society. The welcome improvements introduced in the last 2 years can be regarded primarily as restoring levels of support to those in the late 1960s.

9.24 Inflation has continued to eat into these improved rates. Table 9.3 helps to put the outcome into perspective. Progress on child benefits remains of vital importance. In April 1978 the then Leader of the Opposition Mrs Thatcher affirmed that the child benefit scheme was “a major part of the Opposition’s family policy” (Hansard, 12 April 1978) and the Secretary of State for Social Services, Patrick Jenkin, stated in 1977 that a Conservative administration would give the child benefit scheme ‘top priority’. We would wish to underline the importance of child benefit from the perspective of the health and life chances of children (and, of course,at the same time, their parents). An adequate level of child benefit would have the following advantages:

i. Reduces poverty. Child benefit increases the incomes of those families who fail to claim FIS or supplementary benefits and who are entitled to claim those benefits. It also helps those claiming means tested benefits who, because of particular rules, remain in poverty for certain periods, or qualify only for insufficient amounts. Such statements can be made if what might be called “the state’s poverty standard” is accepted as the criterion of poverty.(Government sources in fact refer carefully to the “supplementary benefit standard” but, as noted earlier (chapter 6) a “poverty standard” or “poverty line” is the description frequently adopted in both scientific and popular usage.) They become stronger if a higher alternative standard, as increasingly urged by some social scientists, pressure groups and even administrators (for example, SBC annual report for 1975) is adopted.
ii. Helps to offset low income or/and loss of income. After several years of high rates of unemployment, and the prospect of further high rates for some to come, child benefit makes an important contribution to family incomes when relatively low wage rates are likely to become increasingly common, and mothers have less opportunity to take jobs to supplement family living standards.
iii. Promotes adequate diet. Definition and public discussion of the amount required by children helps to direct attention to their needs. Child benefit provides an important direct contribution to the dietary and health needs of children and mothers, as well as an important indirect contribution to maintaining family living standards relative to those of single people and couples without children. This has become especially true since the withdrawal of free school milk and food subsidies.
iv. Strengthens mother’s role. The right to obtain the money for children strengthens the mother in planning and catering for the needs of children.
v. Meets additional expenses of children in a changing society. Modern society continues to impose new obligations upon families, including those for the maintenance of health. New types of expenses are associated with the individual child rather than with the family as a whole. For example, the school leaving age has been raised and families are expected to meet new expenses for school kits, transport costs, fares for school trips, domestic science materials and text books. There are continuing pressures, in the schools, clinics and day nurseries, and via the media, to raise standards of child care. In an increasing number of instances, parents are finding that they have to meet educational, health and welfare expenses. (For a discussion of family expenses, see, for example, Bull, D G, 1979).
vi. Anti-inflationary. During the war Keynes and subsequently others appreciated the value of child benefits in limiting the case that can be made in a particular year for wage and salary increases. Child benefit has come to be recognised as an important element in any nation’s anti-inflationary policies. But it can also be an important element of stability for individual families during periods of rapid inflation, when individual wage rates and other sources of income are apt to rise unevenly or remain static. Provided child benefit rates are reviewed annually, a measure of protection for families against high rates of inflation can be provided.
vii. Restores greater equity between those of different age. Recent evidence of the interaction between wealth accumulation and income suggest that there have been trends in living standards in favour of the middle-aged without dependants, as compared with families with children. The spread of salary with increments, house purchase with mortgage periods generally from 20-25 years, and the evolution of structures in industry and public service with seniority rights and better fringe benefits for long-established employees, have all contributed to these trends. New ways have to be found of counteracting these trends in order to prevent social minorities and those with heavy dependancies from experiencing relative deprivation.


Actual amount per week
1 child £ 2 children £ 3 children £ 4 children £
1965 (Oct) 0.91 2.10 3.35 4.60
1978 (Nov) 3.63 7.27 10.90 14.54
1979 (Nov) 4.00 8.00 12.00 16.00
What 1965 values would have been at later dates if maintained in proportion to net income
1965 (Oct) 0.91 2.10 3.35 4.60
1978 (Nov) 3.57 8.31 13.30 18.65
1979 provisional (Nov) 4.11 9.44 15.30 21.45

9.25 In October 1965 the combined value of family allowances and child tax allowances for a standard rate taxpayer with one child was £0.91, with 2 children £2.10, with 3 children £3.35 and with 4 children £4.60 per week (SBC, Low Incomes, 1977, p.90). If these values had been maintained to November 1978 in relation to net incomes of families they would have been £3.57, £8.21, £13.30 and £18.65 respectively. The approximate equivalent values for November 1979 are £4.11, £9.44, £15.30 and £21.45. It can be seen that the rates actually introduced in April 1979 restore the value of family support only for the one child family (and even for that family were likely to have fallen below the 1965 equivalent by November 1979). For families with 3 or more children they clearly fall substantially short of restoring that value. At £4 the child benefit represents only about 4 Per cent of average gross male earnings in late 1979. The short-term rate of national insurance benefit for a dependent child was £1.70 (in addition to child benefit of £4) from November 19799 and the supplementary benefit rate for a child of under 5 was £5.20 and for a child aged 5-10 was £6.25 per week.

9.26 Child benefit should vary by age. Up to the present, supplementary benefits for children and child-tax allowances have varied by age. The supplementary benefit rates for children of different ages from November 1979 are set out below:

£ as % of married couple rate
Married couple 29.70 100
Single householder 18.30 62
Any other person 18 or over 14.65 49
16-17 11.25 38
Dependent child
13-15 9.35 31
11-12 7.70 26
5-10 6.25 21
Under 5 5.20 18

Note: a Ordinary rate only

The range by age is wide and has remained wide since the supplementary benefit scheme, and before that the national assistance scheme, was first introduced. There are powerful arguments for higher rates for children, particularly older children. (See, in particular, Wynn, M. 1970; Walker, C L and Church, M. 1978; Field, F. February 1978; and Townsend, P. 1979, especially chapter 6). A number of those giving evidence to the Select Committee on Tax?Credit argued that child credits should be paid on an age-related basis (Women’s National Commission, Women’s National Advisory Committee of the Conservative Party, the Child Poverty Action Group and Professors Abel-Smith, Atkinson and Kaldor) and the Committee believed “there would not be serious administrative difficulties in introducing differentiated child credits”. (Select Committee on Tax Credit, 1973, p 25). In Western Germany the rates for children are much higher than in Britain. Thus the average rate for children aged 12 to 15 in 1977 was 75 per cent, and for dependants aged 16 to 21 90 per cent of the single householder rate, compared with 51 per cent (for children aged 13 to 15) and 61 per cent (for dependants aged 16 to 17) in Britain (Whittle, C. 1977, P 36).

9.27 In their review of the supplementary benefits scheme a team of officials concluded that the children’s scale rates should continue to be age-related (Social Assistance, P 52) and that 3 age-bands was the smallest number compatible with the principle that could be administered economically. As recently as the mid 1970’s child tax allowances varied according to age and fell into 3 bands: under 11, 11-16 and over 16. The first was 80 per cent of the third.

9.28 The importance of a properly endowed child benefit programme to the future health of the children of this country cannot be exaggerated. Others have endorsed this principle. For example, in its reports for 1975 the Supplementary Benefits Commission stated, “The adequacy of family benefits in general, and the new child benefits in particular, seems to us to be the most urgent concern of the whole field of social security” (Cmnd 6615, P 17). This was reiterated in the next report. “Ultimately we would like to see a level of child benefit equivalent to the allowances we pay for children in families living on supplementary benefit – currently about £5 per week for each child on average”. (Cmnd 6910, p 5). In its response to the “Social Assistance” Review the Commission went on to affirm “Further improvements in child benefit and help for the unemployed – particularly in the form of better opportunities for work – are the most urgent of our proposals”. (Response of the SBC. 1979, P 40). Prom our different remit to examine inequalities of health we endorse those priorities. We recommend as an immediate goal the raising of the level of child benefit to 5.5% of average gross male industrial earnings – in November 1979 equivalent to the rate for a dependent child of a sick or unemployed person (£5.70 including child benefit). In the longer term, we recommend that larger child benefits be paid for older children, perhaps with age bands corresponding to those used by the SBC. Also in the longer term we should like to see age-related child benefit rates index (linked to average gross male industrial earnings or, because an increasing number of women are entering employment and because in many cases both husband and wife have earnings, to some other perhaps more appropriate standard (such as average net disposable personal income). Otherwise it will be difficult to maintain the “tax equity” as well as the “need-serving” functions of child benefit. One parent families present special problems, and in our view their financial needs too would be better met through an increase in child benefit.


9.29 In discussions of the virtues of age-related child benefit attention is sometimes drawn to the financial problems of couples having their first child. Certainly there can be a dramatic fall in family living standards if the wife gives up paid employment to start a family. In exchange for the loss of one of the two wages there are, at least for a time, 2 dependants. Young couples with children also tend to have smaller incomes than older couples with children. But in designing a child benefit scheme it is not possible to meet all such problems of income support. Essentially any system of child benefits must be designed to deal with considerations of needs, or equity, as they apply to families with different numbers of children of different age. Problems of need or equity which arise by virtue of differences in the age, status or conditions of each of the parents, can only be met in a different or complementary scheme. In recent years many countries have begun to recognise that better provisions have to be made for the needs and dependencies of married women. Thus, important changes were introduced in Britain in the Social Security Pensions Act of 1975, and through the introduction of an Invalid Care Allowance and a non-contributory Invalidity Pension for disabled married women. Historically the home responsibilities of married women have been recognised by the development of the Married Man’s Tax Allowance – which has been worth about 1 ½ times his tax allowance as a single person. If the wife goes out to earn, the couple enjoy a tax allowance which is about 2 ½ times the single person’s allowance. At the higher levels of income the couple’s combined income becomes subject to the higher rates of tax. In that situation the wife can choose to be assessed as a separate individual on her earned income, in which case the husband’s married allowance is reduced to a single personal allowance. Reduced tax may then be paid by the couple, which may more than compensate them for the loss of the married allowance. The careful examination of the tax credit scheme in the early 1970s (Select Committee on Tax Credit, 1973) and subsequent comprehensive examinations of the tax structure (for example, the Meade Report, 1978; Field, F. Meacher, M. and Pond, C. 1977) have shown that the tax allowance is inequitable, clumsy and costly as a form of help for mothers in families. With the fall in the number of years during which a married woman is responsible for young children and with the rise in numbers seeking employment, the combined system of income benefits and tax allowances for married women has become more disjointed.

9.30 A re-grouping of resources on behalf of young mothers with children is required. In principle needs at childbirth are met through the maternity benefit and maternity grant. But the grant has not been maintained during inflation and would need to be raised to about £100 (from the present £25.00 which has not been changed since 1969) to restore its value to that equivalent to the payment when first introduced. We recommend that the grant should be increased to £100 to acknowledge the high cost to parents of childbirth.

9.31 The special responsibilities of caring for young children, other than through the married man’s tax allowance, are, however, not yet recognised in Britain. Some other countries (Hungary is one example) have introduced infant care allowances in addition to child benefit. The case for the introduction of a home responsibility payment has been made in Britain. “The benefit would be paid to all families in which there were children or other dependants needing home care, except those where the social insurance benefit included a dependant’s allowance for the wife. In the case of children such a benefit could presumably be paid simply by paying an addition to the child benefit payable for the eldest dependent child in the family, and it might be better presented in this way. The payment for the care of adult dependants would then be a separate benefit, a development of the present invalid care allowance”. (The Meade Report, p 287. See also pp 498~499). The Child Poverty Action Group has proposed a more differentiated scheme, whereby women with children under 5 would receive twice as much as those with dependent children of school age. (Select Committee on Tax Credit, Vol II, pp. 325-30). The allowance could be phased in, beginning with all births after a particular date. We recommend the introduction of an infant care allowance of approximately the same level as of child benefit. to be paid to mothers of children under 5 years of age, to be phased in over a period of 5 years. As suggested later, the cost might be met not so much from new resources as by restricting the scope of the married man’s tax allowance to wives with dependants.

9.32 Beyond these initial elements of an anti-poverty strategy, a number of other steps need to be taken.


9.33 In Chapter 8 we recommended that local authorities should be under a statutory obligation to ensure an adequate provision of day care facilities (taking this term to include not only places in day nurseries but also in nursery classes, and with trained and registered child minders). To emphasize the importance we attach to this recommendation as well as its central place in anv policy devoted to meeting the developmental needs of the under 5s, we further elaborate on it at this point.

9.34 That the desire for day provision on the part of parents of under 5s greatly exceeds what is currently available is well?known. Bone’s survey found that “Provision was wanted for twice as many children as were receiving it, so that whilst 32 per cent of children were using facilities, they were desired for 64 per cent” (Bone, 1977: p. 13). The survey also found this unmet desire to be class-related, as shown in Table 9.4 below. Moreover it is clear that cost is one factor inhibiting usage of what facilities are available, by the children of working class parents. Bone found that among the children of manual workers only, use of facilities fell rapidly with declining weekly incomes. The nature of the facilities available is another factor for it is well-documented that there is considerable difficulty in filling places in nursery schools or classes in working class areas, whereas day nurseries (which are open all day) in the same area generally have long waiting lists.

Table 9.4 Desire for Day provisions for under 5s by class (%) class

Day provision used 40 40 32 29 24
Not used but desired 22 26 36 33 39
Day provisions not desired 37 33 31 36 33

9.35 It is clear that day nurseries, nursery classes, playgroups, childminders and so on meet different needs of families and of their children. Local authority day nursery places are largely restricted to children regarded by social workers as ‘at risk”, or living in poor housing, or where a single parent is anxious to go to work. Staffed by nursery nurses they are less specifically concerned with the child’s cognitive development than are nursery schools or classes. Our own view of the close relationship between health, social well-being, and cognitive development in children leads us to argue for much greater integration between these forms of provision. This is of course widely acknowledged (as in the joint DES/DHSS circular on Co-ordination of Provision for the Under-Fives of January 1978). So too is the need for more flexible provision of nursery education, better catering to the needs of working mothers (CPRS 1978). It must be borne in mind that not only is the proportion of under 5s with mothers in paid employment rising (25% in 1976) but that empty school places represent an inefficient use of resources.

9.36 The needs of mothers for whom financial or other exigencies render paid work essential are only one set of legitimate claims upon the system of day provision. Bone’s survey offers an estimate of the requirement on the assumption that all children in a sense disadvantaged in any of a number of ways should be catered for. The need criteria used (which more or less correspond to those leading to priority admission to day nurseries) were

Child had only one parent Child already allocated to need group A
or Child had 2 parents but father’s income was less than 150% of long term SB level or Child’s mother was worried he might be handicapped (no definite diagnosis)
or Child’s household accommodation 2 or more bedrooms less than standard or Child was 3 or 4 years old and soiled himself more than twice a week
or Child’s household accommodation was inadequate in 4 ways or Child’s mother classified as ‘depressed’ or ‘anxious’
or Child was definitely handicapped (definite diagnosis) or Child had behaviour difficulties (on standard scaling)

On this basis, 15% of all pre-school children fell in need group A, and 36% in need group B. Only 28% of children in need group A were making use of any form of day provision, and 30% in need group B.

9.37 Leaving aside the nature of current provision (and its suitability for individual families and children) the scale is today inadequate to the needs even of deprived children alone. In 1976, in England as a whole, there were 159.9 places per 1000 under 5s in day nurseries (LA and private), playgroups and childminder groups. Additionally, 109.2 per 1000 under 5s (including rising 5s) had full or part-time places in nursery or non-nursery schools. This shows that in England there was provision for 26.9% of under 5s. (CPRS 1978). Since then the nursery school programme has suffered in public expenditure cuts and the situation has undoubtedly deteriorated.

9.38 1976 figures for local authority areas with highest rates of area deprivation or infant mortality (Table 8.9) show that total provision in most barely matches the national average figure of 36% of children in need of such provision. In some cases provision was very much lower eg Knowsley 18.1%, Tower Hamlets (including ILEA average of school places) 29.3%.

9.39 It is not possible for us here to make detailed calculations of the need for day provision. Clearly the unmet need is substantial. On the most conservative of estimates, the difference between the 36% of children whose health and cognitive and psychological development (or financial circumstances with the risks that might ultimately be entailed) make their need for day care overwhelming, and the 27% of all under 5s currently receiving some provision (ie 9% of some 3 ¼ million under 5s in England and Wales) amounts to a minimum need of some 300,000 places. (This of course based on the impossible assumption that all current places are taken up by children in need). If the criterion of parental desire for some day provision were to be adopted, then the number of places available would have to be doubled, according to Bone’s survey. This implies the creation of some 900,000 extra places in England and Wales.

9.40 The health and developmental needs of children, especially children rendered at risk by their environments in so many ways, lead us to emphasise the importance of day facilities for under 5s catering to both these needs, and provided on an adequate scale. The precise pattern of such provision will necessarily vary with local conditions. It is clear that all available resources in the community must be used to their utmost: childminders, voluntary organisations, and parents. More efficient use of existing facilities, such as nursery schools and classes is also required. We are eager to see local authorities sponsoring collaborative arrangements between parents and others in the local community to complement the extended statutory services for the under 5s. This represents the principle of prevention at the local level. To reiterate the recommendation we have already made in Chapter 8: We recommend that a statutory obligation should be placed on local authorities to ensure adequate day-care in their area for children under 5 and that a minimum number of places (the number being raised after regular intervals) should be laid down centrally.


9.41 In Chapter 6 we drew attention to the importance of the nutrition of children for their development. The DHSS booklet Eating for Health stated:

“If all were to enjoy the best possible diet, the variation in average height and weight of different socio-economic groups in the United Kingdom would probably be less marked. The attained height of adults depends to some extent on nutrition during growth as children and in particular during the most rapid period of growth as babies. Any persistent restriction of diet in a young child may impair growth to such an extent that the affected child never reaches its full hereditary endowment of height.’. (DHSS 1978: pp 12-13)

9.42 This booklet goes on to point out the remarkable gains (notably in perinatal mortality) which followed war-time food rationing (despite the overall shortages of food), and the introduction of such welfare foods as cod-liver oil and welfare orange juice:

“The unequal distribution of food, which had restricted the diet of families with low incomes, was made equitable by this system which included food subsidies on and control of the price of meat, bread, sugar, milk, potatoes, butter, margarine, cheese” (p 16).

9.43 The wartime scarcities which led to these policies fortunately no longer exist. It nevertheless remains important to ensure that all children are adequately nourished, if all are to achieve their potential for healthy growth.

9.44 In 1967 the Committee on Medical Aspects of Food Policy commissioned a nutritional survey of pre-school children, which was carried out in 1967-8 and eventually published in 1975. The acknowledged under-representation of large families, poor families, and immigrant families in this survey must to some degree reduce the confidence which can be placed in the assessment of the adequacy of nutrition among these “at risk” groups. The study nevertheless showed a clear decline in vitamin intake (A, C, D) with rising family size, and declining occupational class and income. Protein consumption rose with income though there was no trend on either of the other variables. Calcium intake showed no trend. Total energy consumption actually rose with increasing family size, declining social class, and falling income (except among the poorest families) – but some of this trend was certainly due to extra consumption of “added sugar” (sweets, biscuits, soft drinks etc.) in poorer, larger working class families. (DHSS Reports on Health an Social Subjects, No 10 1975).

9.45 Although the Report concluded that there is “no evidence that our pre-school children were underfed and that “this is true equally for the children of larger families in social classes IV and V and for the children of small families in social classes I and IIII it is hard to see how this conclusion was reached. Distributional data are not given, except that the proportions of children having intakes below 80% of recommended levels of specific nutrients are given for “low income and “other” children.” In fact, though there was virtually no difference between these groups, the proportions were substantial: ranging from 20-30% in the cases of energy, total protein and iron to 45% (low income) and 56% (other) for vitamin C (p 27).

9.46 The survey also showed the importance of milk in the diet of children. Although this was age-related, even at age 3½ -4½ milk continued to provide (on average) 16% of total energy intake, 26% total protein, 62% calcium, and 42 % riboflavin.

9.47 A study of a sample of about 1000 children resident in Kent aged 8-11 and 13-15, carried out between September 1968 and March 1970 throws some light on the nutritional status of older children. The sample employed was deliberately weighted to include larger numbers of children from occupational classes IV and V, large families, and lacking fathers, and included a dietary assessment over a one week period. Important conclusions were that: there was no clinical evidence of nutritional deficiency and significant differences in average daily nutrient intake were not associated with class, number of siblings, or whether or not the mother worked. However, the quality of the child’s diet (expressed in nutrients per 1000 kcals) was class-related: falling with declining occupational class (Cook et al 1973). The study also showed that differences in nutrient intake, and quality of diet, were not explained by income differences when other class-related factors were held constant (Jacoby et al 1975).

9.48 Few today would dissent from the view that adequate nutrition is essential if a child is to enjoy a healthy childhood and to achieve his or her developmental potential. In the absence of a comprehensive food policy attention quite properly focuses on provision of school milk and meals.

9.49 One third of a pint of milk was available free every school day to all school children from 1946 to 1968. From 1968 it ceased to be provided to secondary school pupils. In 1971 it was stopped for all children after the end of the school year of their seventh birthday, except where the school doctor recommended otherwise. Late in 1978 local authorities were once more permitted (though not obliged) to provide milk for 7-11 year olds. In 1971, when the reduced availability of school milk was accompanied also by an increase in the price of school meals, the Committee on Medical Aspects of Food Policy (COMA) was asked to monitor the effects of these changes. Its Sub-Committee on Nutritional Surveillance issued an interim report in 1973 in which it indicated the dimensions on which effects would be monitored: height, obesity and dental caries were central.

9.51 So far as provision of milk to primary school children aged 7+ is concerned, the evidence – though not clear cut – does not indicate a significant effect on growth. The earlier study of Kent children to which we referred above, conducted in 1968-70, found that among 8-11 year olds, those who regularly drank school milk had significantly higher intakes of energy, calcium, and animal protein, but that this was not associated with height or other measures of nutritional status (Cook et al 1975a). The same research group, conducting a national surveillance study of a longitudinal kind under COMA auspices found that between 1972 and 1973 the growth of 6-7 year olds was not influenced by availability of school milk. The same held true of a special sample of children from occupational classes IV and V (formed by aggregation of successive age cohorts) (Cook et al, in press). A study of 7-8 year olds in South Wales, employing a sample deliberately weighted in favour of large families, and occupational classes IV and V, also found that growth over 21 months was unaffected by provision of school milk (Baker et al 1978). Cook et al summarize by stating “the availability of school milk has no real effect on group well-being where drinking milk at home is almost universal”. It has however been suggested that linear growth may not be a wholly adequate measure of the benefits of milk consumption. Reed, for example, has referred to the need also to take account of bone status (Reed, 1978).

9.51 Moreover, current policy towards provision of school milk has to be judged, and developed, in the light of the continuing fall in household consumption of liquid milk revealed by the National Food Survey. In 1977 this average household consumption was 4.54 pints per person per week, compared with 4.71 Pints in 1976 and 4.76 pints in 1975 (National Food Survey, 1977: P7). Moreover, the Survey shows that in 1977 of 7-9 year olds in lower income families with 3 or more children, 12% consumed less than 2 pints per week in the home, and over 25% less than 3 pints.

9.52 It is clear that current policy must therefore be kept continuously under review, in the light of these trends, and also in the light of further research on growth and development.

9.53 The evidence in relation to provision of schools meals is more clear cut.

9.54 School meals are intended to provide about one third of the daily allowance of nutrients and energy for a child, and are recommended to contain, on average, 29g. total protein, 880 kcals energy, and 32g fat. We have no evidence as to the range in nutritional quality of the meals in practice provided. We have no doubt that this meal is the principal source of essential nutrients for many poor children. Many may be offered a poor quality evening meal, and many come to school without breakfast. (This 16 hour ‘fast’ may well affect the child’s powers of concentration, and hence his ability to profit from his schooling). It should be regarded as a matter of importance – on education and health grounds – to ensure that all children receive a school meal or an adequate substitute at least during term time. To leave schoolchildren, especially young school children, to make their own free choices as to what food is to be purchased would be wrong. Children will frequently prefer to consume foods high only in sugar and other sources of energy. As an inadequate substitute for a nutritious meal, this is likely to lead to increases in obesity and in dental caries.

9.55 Certainly, great importance has been attached to the nutritional variety and adequacy of school meals by a number of official committees. For example, the Working Party on the Nutritional Aspects of School Meals has commented “We do not think it is safe to assume that all children necessarily receive a satisfactory diet at home. We are especially concerned that all children should receive enough protein at school since any shortfall in the midday meal might easily not be made up in other meals or snacks and drinks consumed outside school”. (DES 1975, P8).

9.56 The survey of Kent children aged 8-11 and 13-15 offers some support to these views (Cook et al 1975b). Consumption of school meals (about 80% overall) proved to be higher among children without fathers, with working mothers, etc. Distinguishing children who had all 5, or no school meals in the test week, the study found that younger children who had school meals had higher lunchtime intakes of nearly all nutrients (and more nutrients per 1000 kcals) than those who did not. It also found that children from classes IV and V taking school meals obtained a very much higher proportion of their total weekday nutrient intake from their lunches than did children from the same classes who did not. The same was not consistently true of class I/II children.

9.57 Taking these findings together with known biases in consumption of school meals, it is possible to conclude, with the authors, that “families without a father, those in lower social classes, and with large numbers of children relied to a greater extent than others on the intake of nutrients important for growth from school meals. This reliance may or may not depend on a conscious decision. The present study took place before recent large increases in the cost of protein – rich foods and such families may now rely even more on the food intake from school meals.”

9.58 Yet the percentage of pupils receiving school meals (whether free or paid is falling: from 70% in 1975 to 62% in 1977.

9.59 Partly because of cost, partly because of poor quality but partly because of administrative inertia a very large number of pupils do not have meals at school. We believe that the number of schools with facilities for providing meals for all or most of their pupils can be increased, and that more consultation with parents about the organisation and administration of meals would be an important element in raising quality. Children from families living in poverty sometimes attend schools lacking facilities for meals, and although others go home at mid-day for meals because their parents believe they can provide a more nutritious meal for them, there is no doubt that some would get meals at school if they were an automatic right.

9.60 The attitude of a school does seem to influence the consumption of school meals and the eating habits of children generally. The importance of adequate nutrition for a child’s physical development and concentration in school must be brought home to teachers. In this community dieticians have an important role, and one which is not facilitated by the size or priority typically attached to the service. Meals are also social occasions, when some of the intentions of an education can be consolidated -through example as well as instruction and free conversation. School staff are apt to underestimate the value of social relationships that can be developed.

9.61 A second factor is that of the cost of school meals (about to rise drastically in the current period of public expenditure cuts), and the availability and up-take of free meals. In May 1978 some 15% of pupils received free school meals.

9.62 Recent results from the Surveillance Study being carried out by the St Thomas’ group show that children receiving free school meals are significantly shorter than those who do not. Though the study was not designed to assess the value of school meals in terms of growth, the indications are “that free school meals are going to the right group of children and that withdrawal might well prejudice their future development” (Rona et al 1979).

9.63 At present local authorities administer a Government scheme making school meals free for children of parents receiving Supplementary Benefit or parents whose income is below certain limits laid down in national regulations. The limits are revised regularly, normally when Supplementary Benefit scales are increased. In recent years the Department of Education has estimated that about three-quarters or four-fifths of children eligible to receive school meals free are in fact receiving them. Others consider the right figure may be no higher than 60 per cent. Part of the problem arises In fluctuating incomes and frequent assessments or reassessments, but also in the fluctuation in standards of living brought about by changing household dependencies. Experimental campaigns by the Government, especially in 1967 and 1968 under Mr Gordon Walker, have shown that take-up can be increased substantially through letters addressed directly to parents and through advertisements. But because of the numbers of children passing through the schools and fluctuations in family living standards, quite apart from the effect of inflation, higher take-up rates do not endure. Twice in 1977 and again in 1978 the Secretary of State for Education was asked to renew the approach adopted by Patrick Gordon Walker and issue a simple letter to all parents advising them about free school meals. Although an estimated half of million children were not obtaining free dinners although entitled to them, this invitation was not accepted. Whatever the exact short-fall, there is no doubt that it is substantial and there have been a large number of research studies demonstrating that means-tested exemption from charges for school meals is not a satisfactory way of helping poor families (Davies and Redding, 1978: Field, 1975; 1975: Townsend, 1979). A recent study has shown that there are even wide variations among areas with similar characteristics. ‘This type of analysis can help to identify areas where there may be low take-up to inadequate efforts by local authorities and central Government’. (Bradshaw and Weale, November 1978, p 22).

9.64 In our view any reduction In the provision of school meals, or in eligibility for free meals, would mean putting further at risk the development of significant numbers of children. Moreover, from the perspective of this report, it is clear to us that expansion in such provision, elimination of inequalities of provision, and elimination of the barrier to take-up which means-testing represents, are essential aspects of a policy designed to break the continuing association between social class and health in its broad sense. We are aware that much of what we have said about school meals is very different from current government policy and much orthodox opinion in the teaching profession. Nevertheless, in our view the evidence strongly supports a change of direction.

9.65 We accordingly recommend:

i. That the provision of nutritionally adequate meals at all schools should be required of local authorities and that the service should be extended in areas where there is under-provision;
ii. That there should be regular consultations between local authority representatives, community dieticians, and parents and teachers from each school in turn over the provision and quality of school meals;
iii. That meals be provided in schools without charge.


9.66 In chapter 2 of this report we have drawn attention to the fact that the most steep gradients in childhood mortality are found with accidents., a fact which is all the more disturbing now that accidents account for one-third of deaths of children. Moreover there has been little improvement in this class differential over the period 1959-63 to 1970-72 (see table 3.12). It is remarkable given these facts and given that there is a known course of action which could be put into effect rapidly without great cost to the public, that so little has been done.

9.67 Although accidents in the home are not the largest single groups of accidents to children it is probably in the home that major progress could be made most quickly. Regulations could be introduced immediately to produce a safer home environment for children and these could be applied stringently to public housing. Risks of falls from roofs and staircases can be reduced without great cost by safe design; the positioning of windows being particularly important. Much could also be done to reduce the dangers from household equipment, especially the dangers from fire and burning. There is still a great deal which can be done to reduce the risks of poisoning by the clearer packaging of dangerous substances. Although important work has been done by RoSPA and the Health Education Council in educating the public it is likely that ‘safety devices built in as a constant feature of the environment are more effective than attempts to alter people’s behaviour’.

9.68 The problem as elsewhere in preventive health is that there is no focus for government action, and although the new voluntary Joint Committee on Accident Prevention may help, a clear initiative is needed from a powerful Minister if adequate co-operation is to be forthcoming from the Department of Environment, the Department of Trade, and the local authorities.

9.69 The environment outside of the home has become increasingly dangerous to children since the spread of ownership of motor cars, but children who live in the overcrowded industrial areas of our cities are also exposed to the dangers of industrial traffic. Despite the laudable attempts of town planners to separate vehicular traffic from pedestrian ways there are still over 700 children killed on the roads each year. Once again although it is important to give due recognition to the accident prevention campaign in schools and elsewhere the reliable answer is to give children safe areas in which to play. Moreover if there is a need to step up safety education it is the motorists (especially the young driver) who should be the target. Motorists need to be made more sensitive to the presence of children in the areas they drive through, and conscious of the way in which children behave on the roads.

9.70 Apart from the specific dangers of road traffic it is likely that the working class child lives in a more dangerous physical environment than middle class children. Derelict slum housing about to be cleared, deserted canals, mine shafts and factories, railway lines, rubbish tips; all these present potential dangers to the child in the urban-industrial area. Given the ingenuity and sense of adventure of children it is difficult to conceive of such areas ever being made danger free, but more could be done by environmental health authorities to monitor the risks and keep the owners of such properties up to the required standards of safety production.

9.71 When accidents happen there is no lack of concern for the child to see he gets the best treatment possible, but unfortunately public attitudes soon return to their normal complacency. If childhood accidents are to be reduced and the gradients between social classes minimised, the issues must be kept before the public gaze. The voluntary organisations both local and national have the important role here in stimulating the political will for action.

9.72 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.


9.73 We have outlined a 5 part policy designed to improve the standard of living of families in ways which we feel will particularly aid the healthy development of children born into disadvantageous circumstances. These include: an increase in child benefit, in the short-term in relation to earnings to £5.70 per week (as at November 1979); the introduction over a period of 5 years of an infant care allowance to mothers looking after small children, together with an increase in the maternity grant to £100; an expansion in day provision for pre-school children; and the free provision of school meals to all pupils.

9.74 The annual costs of our proposals might be roughly as follows:

1. increase in child benefit from £4 to £5.70 for each child: £970 million( The cost of a 50p increase is estimated at £285 million (Secretary of State for Social Services).)
2. infant care allowance (on assumption that there are 600,000 births per annum): £180 million in first full year (rising to £870 million after 5 years)
3. expansion of day provision:£150 million ( This is the annual expenditure recommended by the CPRS for a programme of expansion directed at similar objectives to our own (Services for Young Children with Working Mothers, p 27))
4. free school meals: £200 million (on the assumption of 4 million meals per day served on payment (1977 figure 3,929) of 25p over 40 5 day weeks annually)

9.75 Clearly resources on this scale cannot at present be found without at least substantial offset from savings elsewhere. We have already called attention to the discussion in 1972-3 of the possible substitution of a tax credit for married man’s tax allowance (Cmnd 5116 and Report of the Select Committee on Tax Credit 1973). More specific proposals to substitute a home responsibilities cash allowance for married women with dependent children have also been made (Meade Report, 1978; CPAG Evidence to Select Committee on Tax Credits 1973). We would point out that the estimated cost of the married man’s tax allowance in 1979?80 was £7,800 million of which some £2,800 million represents the excess over the single person’s allowance. At any one time some 50% of married couples do not have dependent children, although of course some will be caring for other dependent relatives or will themselves be elderly. We do not regard it as our function and nor are we technically equipped, to make specific recommendations as to how the costs of our proposals might best be met. We would suggest, however, that the additional tax allowance, now made to married couples without dependents be considered as a source of savings to be set against the proposals we have made for increasing the well?being of families and children.


1. A Comprehensive Disablement Allowance

9.76 We will now turn to measures directed principally at others than families with young children. Policies affecting disabled people must also be given priority. We have called attention to the importance of understanding “disability” in terms of restriction of activity relative to what is normal (Chapter 1) and we see this as a major means of achieving a more equitable distribution of income and services among people of different age and with different types of impairment (including mentally and not only physically handicapped people).

9.77 There is evidence that proportionately more disabled than non-disabled people of different ages are living in poverty or the margins of poverty (Table 9.5). There are also indications that among the disabled income is inversely related to severity of disablement. In Harris’ study it is stated that “Nearly one in 10 of the very severely handicapped has, by our estimation, an income at least £1 below requirements, compared with nearly one in 20 of those with minor or no handicap” (Harris: p 12). Another national study found a relationship between both decreasing income and decreasing total resources and increasing severity of disablement (Townsend, 1979, Chapter 20). During the late 1960s and early 1970s a strong case was developed publicly for the introduction of a comprehensive allowance scheme for disabled people. It was felt that equally severely disabled people were very unequally treated under different income security schemes. While there were fairly elaborate provisions for the war disabled and those disabled in industry those who were injured in home accidents, people who were congenitally handicapped, disabled housewives and disabled elderly people had little or no entitlement to additional income. But in 1974, while adopting different positive proposals for improvement of income benefit, both major political parties failed to commit themselves in principle to the phased introduction of a comprehensive scheme. Major anomalies exist and have been documented at length (Royal Commission on the Distribution of Income and Wealth, Report No 6 (1978): Chapter 4; PP 115-119; 152) The Snowdon Working Party (1976): “The evidence clearly demonstrates the need for the fundamental methodical reforms advocated (by DIG and the Disability Alliance) to rectify the anomalous structure of disablement benefits whereby 2 people with equal handicaps and needs may end up with widely differing financial help to meet them” (p 9).

Table 9.5 Numbers and percentage of total and disabled population living in poverty or on the margins of poverty (1977)

Level of income Total Population Disabled over pensionable age (000s) Sick and disabled under pensionable age(000s) Disabled of all ages (000s)
Over pensionable age (000s) Under pensionable age (000s) All ages (000s)
Below Supplementary Benefit level 760 1270 2020 250 70 320
Receiving Supplementary Benefit 2000 2160 4160 790 240 1030
At or up to 40% above Supplementary Benefit 3010 4830 7840 860 400 1260
More than 40% above Supplementary Benefit 2750 35960 38720 690 1380 2070
Total 8520 44220 52740 2590 2090 4680
Below Supplementary Benefit level 8.9% 2.9% 3.8% 9.7% 3.3% 6.8%
Receiving Supplementary Benefit 23.5% 4.9% 7.9% 30.5% 11.5% 22%
At or up to 40% above Supplementary Benefit 35.3% 10.9% 14.9% 33.2% 19.1% 26.9%
More than 40% above Supplementary Benefit 32.3% 81.3% 73.4% 26.6% 66% 44.2%
Total 100% 100% 100% 100% 100% 100%

9.78 After allowing for savings because of existing schemes, the introduction of a disablement allowance by stages has been costed at a little under £500 m. (Disability Alliance, 1978). Included in this estimate of costs are disabled elderly people. We believe that the establishment of such an allowance represents a major means of reducing inequalities of health and restoring equity between disabled and non-disabled people and we recommend accordingly that a comprehensive disablement allowance for people of all ages should be introduced by stages at the earliest possible date. There are of course other supporting measures, especially in improving the employment of disabled people and wage-rates, which are important. We believe that the first step must be to establish equity for the most severely disabled people of all. At the present time there is a choice between introducing an allowance at a low rate, say £6, for all severely disabled children and adults in supplementation of other income benefits and developing a scheme parallel to the main features of the war pensions and industrial injuries disablement pension schemes (into which the mobility allowance might be merged), introducing first a 100 per cent rate of payment (equivalent to the rate of £38 per week payable from November 1979 under the war and industrial injury disablement pension schemes). Even if the aggregate national sum available under either option were the same we believe the latter would be the right option. The net cost of establishing an allowance for 100 per cent disablement (ie the first stage) for people of all ages and causes of disablement would be approximately £24 m at November 1979. (At November 1978 the cost was estimated by the Disability Alliance at £20 m).


9.79 In our studies of inequalities in health we have been struck by the ill-developed nature of conceptions of and deprivation at work. Although the hazards of working in particular industries have been carefully documented in the past, and detailed studies made of hours of work and conditions in which strikes and other conflicts between management and labour have occurred, generalizations of working conditions or work situations across industries have not been pursued very far. The point can be made by analogy. Generalization about diets, clothing, leisure time pursuits, housing conditions and even environmental conditions are readily made. Thus, standards of overcrowding, facilities and amenities are defined nationally for housing and are commonly understood and discussed. As a consequence, discussion about remedial measures is based upon statistics about the numbers who live in overcrowded or slum housing and lack particular amenities. Such standards do not really exist for the world of work. There are no measures of the number in employment who have bad or deprived conditions of work. the industries or areas in which they are to be found and the degree to which they also experience bad housing conditions and low incomes.

9.80 So far as health is concerned the emphasis has been on safety and specific identifiable risks of accident or of contamination by toxic substances. For example, the Robens Committee did not attempt to collect evidence about safety and health in relation to general working conditions. Neither did they attempt to pursue the inter-relationship between fatal accidents, deaths and injuries arising from prescribed industrial diseases and occupational mortality and morbidity – for each of which independent sets of statistics exist. The importance of reports on occupational mortality to a better understanding of the work situation as well as to the circumstances outside work remains to be plumbed.

9.81 Elsewhere we have called attention to the inequalities in death rates between people belonging to different occupational classes. We have referred only briefly to inequalities between people following particular occupations. In Table 9.6 the wide differences between some occupations are illustrated. The marked gradient from sedentary non-manual to heavy unskilled manual work, which with some exceptions the Table shows, is accompanied by wide variations between the mortality rates for specific occupations within each occupational class. Specific and well known work hazards, characteristic of many manual occupations, and differing from one to another, are one factor here. In the light of the analysis of this report, we consider that in addition to these hazards. and associated risks of accidents and of certain occupational injuries and diseases, a wider variety of job characteristics may be implicated. These would include security and material rewards of employment, patterns of work (eg shiftwork), conditions of work and welfare and other amenities. The extent to which work conditions, interpreted in this broad fashion, are responsible for differences in rates of occupational mortality remains uncertain and requires further research, (although see for example Fox and Adelstein, 1978).

9.82 Nevertheless, reduction in inequalities between occupations in their work conditions may be of importance in reducing inequalities in health. We recommend that representatives of the DHSS, the Department of Employment, the Health and Safety Commission, together with representatives of the trade unions and CBI should draw up minimally acceptable and desirable standards of work; security; conditions and amenities; pay; and welfare or fringe benefits. A national study found that in 1968 20 per cent of the employed population, representing over 4 ½ million people, had poor conditions of work (Townsend, 1979, p 453). A list of individual examples from a random sample called attention “both to the diverse hazards and frequent poor conditions of manual work”. They also suggest uncertainty or ignorance on the part of many about the hazards involved with dust, noise and chemicals. For whatever motives, doctors as well as employers may withhold information, and the importance of the role of union safety representatives (the legal right to which workers have enjoyed since October 1978) is clear. There is still a tendency to accept poor working conditions as an inevitable accompaniment of particular jobs, and attention needs to be devoted to the question of enlightened standards which can be introduced, as in public housing and town planning. Among the matters which we hope will attract more attention are facilities for meals, warmth and shelter from bad weather, a dry and secure place for outer clothes and other belongings, access to a telephone, availability of first aid and first aid equipment, “unsocial” hours, warmth, humidity, light, noise, availability of machinery to avoid or reduce the physical stress of the work, washing and toilet facilities, and facilities for changing clothes. In many of these instances regulations under current legislation are non-existent, or partial, or complex and confused (TUC 1978).

9.83 We are calling for more preventive work by Government departments, employers and unions and would hope to see a shift of emphasis in the work and functions (as defined by legislation) of the Health and Safety Commission and Executive, and the Employment Medical Advisory Service. It is fair to say that although there are provisions for both bodies to follow positive policies they are at present apologetic for restricting their activities to specific hazards and general questions of safety. (See for example the references by the Chairman of the Health and Safety Commission to its work on the “preventive aspect of occupational health” and of his office to the preventive functions of the occupational health services in Occupational Health Services, 1977, pp v and 15-16). The need for legislation defining acceptable working conditions and basic employer welfare benefits is urgent.

Table 9.6 Mortality by occupational unit: Men aged 15-64 (selected examples

Occupational unit Direct age-standardised death rate per 100,000 SMR
Relatively low death rate
University teachers 287 49
Physiotherapists 297 55
Paper products makers 302 50
Managers in building and contracting 319 54
Local authority senior officers 342 57
Company secretaries and registrars 362 60
Ministers of the Crown, MPs, Senior Government Officials 371 61
Office managers 377 64
Primary and secondary school teachers 396 66
Sales managers 421 70
Architects, town planners 443 74
Civil service executive officers 467 78
Post men 484 81
Medical practitioners 494 81
Relatively high death rate
Coal miners (underground) 822 141
Shoe makers and shoe repairers 898 156
Leather products makers 895 147
Machine tool operators 934 156
Watch repairers 946 154
Coal miners (above ground) 972 160
Steel erectors, riggers 992 164
Fishermen 1028 171
Deck, engineering officers and pilots, ship 1040 175
Labourers and unskilled workers, all industries 1247 201
Policeman 1270 109
Deck and engine room ratings 1385 233
Bricklayers’ labourers 1644 274
Electrical engineers 1904 317


9.84 Housing conditions are associated with health status in a variety of ways. Inadequate heating (or a form of heating which is too expensive for a resident) can give rise to hypothermia in old People (Wicks, 1978). Overcrowding can produce respiratory and other diseases (some of the studies are reviewed by Benjamin, 1965 who, however, pointed out that class explained more of the inter-area variance than housing). It can also produce adverse psychological responses and may give rise to mental illness. High rise living is known to have deleterious consequences for children. In some areas (eg Tower Hamlets) TB is common among the homeless vagrants and represents a real problem for the health authorities. The consequences, and importance, of housing policies for other areas of social policy, including health policies, have received increasing recognition in recent years – as have the problems of co-ordination deriving in part from the location of responsibilities for housing and personal social services (outside London and the Metropolitan Counties) and Health services. These interactions, and organisational problems, have recently been discussed in a report of the Central Policy Review Staff, (CPRS, 1978b).

9.85 Earlier in our report we have presented evidence for the association of poor housing (and particularly overcrowding) with a number of indicators of mortality and morbidity. Brennan and Lancashire, for example, found a high statistically significant ecological correlation between proportion of population living at one or more persons per room and mortality rate among 0-4 year olds (Brennan and Lancashire, 1978). Correlations with mortality among 5-15 year olds, and between each of these mortality indicators and proportion of the population living at a density of 1 ½ or more persons per room were also significant, though smaller. Moreover, these correlations persisted when the effects of the class compositions of the areas (county boroughs) were held constant. A regression analysis of data relating to the Dutch city of Rotterdam also found a significant relationship between density of occupation (persons per room) and age adjusted death rate (though in this case not with perinatal or infant death rates) (Herzog, Levy and Verdonk, 1976). That overcrowding has some causal relationship with health (through, for example, increased risk of infection of younger by school age siblings) seems certain. It is families with children, and especially large poor families with many children who are most likely to be living in overcrowded conditions. This is shown by Table 9.7, taken from the 1971 census. Of 5 person households (which includes 3 children 2 parent families), 20 per cent of those in privately rented furnished accommodation were living at more than 1 1/2 persons per room, compared with less than one per cent of owner-occupiers, of 6 person households (ie including 2 parent families with 4 children) 20 per cent of furnished tenants were living at more than 1 ½ persons per room and 57 per cent at more than one person per room. Among larger households, in both private furnished and council tenancies, the degree of overcrowding rises rapidly. Overcrowding adds to the health risk under which working class children labour, and the extent to which such children, and especially those born into larger families, are being brought up in overcrowded conditions is unacceptable.

Table 9.7 Overcrowding: Proportions of households of different sizes living in permanent dwellings living in overcrowded conditions for three tenure groups (1971)

Number of persons in household
owner occupiers renting from council or New Town Private furnished tenant All tenure groups
persons per room (%households) persons per room (%households) persons per room (%households) persons per room (numbers and % of households)
> 1 1/2 1-1 1/2 > 1 1/2 1-1 1/2 > 1 1/2 1-1 1/2 > 1 1/2 1-1 1/2
No % No %
3 0.0 0.2 0.0 0.5 6.9 16.0 9225 0.3 39015 1.2
4 0.1 0.9 0.3 4.2 12.8 12.4 19490 0.7 79545 2.9
5 0.9 7.1 2.5 13.4 20.4 14.4 34125 2.6 142415 10.7
6 1.3 31.2 1.7 63.5 19.2 37.9 13655 2.4 269395 46.4
7 7.6 54.7 10.3 80.9 28.8 46.9 21945 10.4 144180 68.3
8 29.2 47.2 51.9 46.1 45.3 39.9 40720 43.3 43160 45.9
9 29.9 57.9 45.3 53.9 48.0 44.1 16355 40.0 22400 54.7
10 67.4 27.1 83.1 16.5 71.4 18.4 25595 76.5 6930 20.7

9.86 Bone’s survey of pre-school children found that 10% of the children inhabited dwellings inadequate on at least one of 4 criteria: overcrowding; no separate unshared bathroom; shared WC; no sole use of permanent fixed hot water supply (Bone, 1977: p 26). But this percentage was highly class related: 3% in class I increasing to 29% in classes IVM and V.

9.87 The adequate housing of families with children must be a priority if class inequalities in health are to be eliminated. Clearly the situation is worst in the private rented furnished sector, but it would seem that there is also a need for the construction of many more Council dwellings which can adequately accommodate families with several children (or a combination of children and other dependants). Medically acknowledged ill-health which is clearly exacerbated by poor housing conditions does generally establish priority on housing lists, and this is as it should be. But the risk of ill health – in the case of children a lifetime of ill-health, for chronic respiratory disorder (for example) in childhood is an all too effective predictor of adult suffering – is established on socio-medical rather than clinical grounds. Such considerations tend not to weigh as heavily with housing departments as they should.

9.88 We showed, in Chapter 2 (on the basis of the new OPCS longitudinal study), that there is an association between tenure and SMR, independent of the occupational class of the household head. Of course, this does not demonstrate that being a tenant causes ill-health. But we wish to stress that the rights and privileges which are so unequally associated with housing tenures are associated also with health in its positive sense (of welfare). Fear of eviction is the sort of situation which Brown has shown to be related to clinical depression in women. Security in housing does have health benefits and should be equally available for all. Accessible play areas for young children are vital and owner-occupation often meets this need, by virtue of garden space available. Gardening is one of the most popular outdoor leisure pursuits for men in Britain who have access to a garden, and we have already indicated the health benefits attaching to active outdoor recreation. We believe that there must be a much greater extension of the rights and privileges associated with owner occupation to the tenants both of local authorities and private landlords. Health considerations are certainly among the factors which justify such extension.

9.89 In order to allow good housing policy to play its part in promoting health we consider the most essential step is to co-ordinate policies in the council and owner-occupied sectors. The changing pattern of housing tenure has been leading to problems of access to housing for the poor and mobile, which have gradually become more acute in recent years. Only in part has that been due to the decline of the privately tenanted sector. In part has been due to rigidities in the management of council housing, together with a very uneven flow of new housing. There needs to be a more vigorous programme of rehabilitating rented housing which is becoming obsolescent. This includes many thousands of council housing units. Comparisons need to be made between the tenures so that priorities in improvement policies and the allocation of resources, but also new standards of space, amenities and access to play areas, including gardens, can be determined. We therefore recommend a substantial increase in local authority improvement spending under the 1974 Housing Act.

9.90 But broad equity between the sectors must be achieved in other ways as well. The previous administration tended over-optimistically to reiterate the view that there was no longer any overall shortage of housing, while allowing local authorities to refuse housing to such groups as homeless single and childless couples. Secondly, the rights and opportunities of tenants need to be reviewed in the light of conditions enjoyed by owner-occupiers. The previous administration experimented with a “Tenants Charter” but in some respects this was half-hearted and among the most important measures to be introduced are freedom of movement, freedom to carry out minor improvements and repairs (and benefit from them in the terms under which the tenancy may be passed on subsequently), greater freedom in the rules of residence and more effective representation in the management of housing estates. Consideration of council house sales badly needs to be placed in the context of the relationship between the sectors. If, in the long run, a better balance could be struck in the conditions enjoyed in the 2 sectors, objections in principle to interchange of stock could be minimised. But indiscriminate sales may worsen housing opportunities for families needing to rent; they may reduce the quality and attractiveness of the council housing stock; and introduce a new basis to the relationships in many estates they may affect the cohesion of existing communities.

9.91 The Housing (Homeless Persons) Act, 1977, gave local authorities a statutory duty to house the homeless. A step was taken towards making council housing a right rather than a privilege for homeless people, to widen the categories eligible for re-housing. “The Act required even authorities which had pursued fairly liberal policies to accept people they had not previously regarded as priority cases: pregnant women, people homeless after family disputes, the mentally handicapped”. (McIntosh, 1978, P 516). It is still a little early to judge the full effects of the Act and though there has been a significant increase in the number of households for which councils have accepted responsibility to re-house, there remains some controversy about the extent to which the categories intended to be helped, are helped. For example, one Director of Housing (Camden) has stated that “What the Act has done is to transfer a large number of families with a housing need for an authority’s housing waiting list [ie separate families, families living in overcrowded conditions, and families without security of tenure living with relations or friends, or in hotels or hostels, or squatting] to its homeless persons section”. (Barnes, New Society, 1978). A number of housing charities have argued that councils are too free to place their own interpretation on the Act; that some councils are exploiting the loop-hole of “intentional” homelessness; that the Act and the code impose no standard for homeless accommodation and that the single homeless are not sufficiently covered by the legislation.

9.92 We believe the legislation on homelessness deserves strengthening along the lines recommended by the housing charities. With the dwindling of the private rented sector, local authorities must provide rented accommodation for a wider range of households, including the single and childless, who are unable to enter owner-occupation. We recommend, therefore, that local councils should increasingly be encouraged to fulfil their responsibilities to provide for ALL types of housing need which arise in their localities.

9.93 A further aspect of the relationship of housing to health to which we wish to refer concerns the housing of the disabled. Here in particular is demonstrated the need to consider factors other than over-crowding in assessing the adequacy of housing for an individual or family. If the unnecessary institutionalisation of disabled people is to be avoided (as we have recommended) then clearly there must be sufficient provision of sheltered and adapted housing. It is necessary for there to be much better working relationships than is frequently the case today between social service and medical authorities and housing departments, so that necessary adaptations to dwellings can be obtained easily. We have elsewhere recommended that serious consideration should be given to the possibility that social service departments assume responsibility for the management of sheltered housing. A second aspect of such collaboration concerns policy over the re-housing of disabled people, which seems generally to be inadequate. The Working Party on Housing of the Central Council for the Disabled wrote in its (1976) Report, of local authority policy:

…. unless the disabled person also happens to be living in overcrowded accommodation with few amenities, his position on the waiting list is likely to be low indeed, even if he has the maximum medical points possible …But the housing difficulties that are peculiarly associated with disability require a separate type of solution the priority given to disabled people should not be decided at an individual level – as tends to happen at present – but should be decided within an overall strategy of priorities within the housing policies of the authority as a whole.

… The existing system means that a disabled person may not be rehoused until the situation has reached a desperate pitch. By that time the move may really be too late: his physical condition may have deteriorated too rapidly – possibly aggravated by his inadequate housing – so that he is not in a position to settle into a new environment …Where a disabled child is concerned, to move the family to suitable housing when the child is grown and the situation has reached breaking point, may work against the educational development of the child and his ability to learn to cope independently . …..

(Working Party on Housing of the Central Council for the Disabled,Towards a Housing Policy for Disabled People (1976), pp58-60)

9.94 We therefore recommend that special funding on the lines of joint funding for health and local 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 service and housing departments. This recommendation is on the same lines as that made by the Snowdon Committee which argued that one immediate priority was “to develop a real choice of life-style for the severely disabled through joint planning and financing by the Department of Environment and the Department of Health and Social Security”. We also endorse that Committee’s plea for the “urgent establishment of schemes for non-institutional accommodation for severely disabled people living in every area of the country”. (Report of the Snowdon Working Party, 1976, p 32).


9.95 We believe that improvement in the nation’s health should be a priority for government. The evidence of various indicators of mortality shows that in this respect Britain’s record in recent years has not compared well with other countries. We should like to see drastic reduction in rates not only of perinatal and infant death, but of the extent of chronic and acute sickness and of physical and mental handicap (much of which develops in the period around birth), as well as promotion of health in its positive sense of “well-being”.

9.96 The costs of sickness – the direct costs of the National Health Service, of supporting care, and of sickness benefits, as well as the indirect costs of sickness for productivity – though not easily calculated in toto, are very great. Acute care provided in hospitals demands an increasing share of national resources. The financial costs of bouts of ill-health, chronic sickness and handicap to individuals and families – especially poor families – are frequently immense. These private costs are not fully captured in financial terms. The alarming prevalance of depressive illness, especially among working class women, cannot be without profound effect on family life and child-rearing, irrespective of the misery the women themselves suffer.

9.97 It is also our view that the attempt to reduce, and ultimately eliminate, the social inequalities in health which we have documented, offers the greatest opportunity for achieving this overall improvement. It is surely no accident that (as we showed in Chapter 5) those countries, such as Sweden and Norway, which have particularly low mortality rates, also seem to have greatly reduced inequalities in health. This argument – that reduction in the burden of sickness on working class families offers the greatest scope for overall improvement in the nation’s health – is quite separate from the argument (to which we also attach great weight) that simple justice demands that this attempt be made. Part of what is required involves attention to those regions and small areas (for example in the inner cities) where concentrations of sickness are high and levels of service provision low. But part involves attention to improvements that can be made and new measures that can be introduced for families in all areas of the country. And part involves attention to the vicious cycle by which (through a variety of mechanisms) poor families are locked into material, educational, environmental and social disadvantage for a lifetime and even sometimes for generations, with all that this implies for their health.

9.98 Our analysis has shown that inequalities in health have complex, multicausal explanations. They are rooted in the general nature and conditions of activity, both in work and outside work, and in the styles and standards of living of different social classes. Some factors have a clear causal association with ill-health: inadequate access to and use of (particularly preventive) health services; the hazards attaching to certain occupations; overcrowded and damp housing; smoking, and so on. But there remains much that is probably not explicable in any direct fashion, and must be attributed to the pervasive effects of the class structure.

9.99 It follows, and our recommendations reflect this fact, that reduction in health inequalities depends upon contributions from within many policy areas. Our recommendations have involved reference to community and preventive health services; to the personal social services; to health education in a very broad sense (including the promotion of physical recreation); to social security measures; up-take of school meals; to improvement in working conditions; housing; and to measures directed specifically at minority groups and notably in inner city areas. Clearly such a range of services and policies involves many departments of central government: DHSS, DOE, DES, DE (and the Health and Safety Executive) MAFF, Department of Transport and the Home Office, as well as the Welsh Office and the Scottish and Northern Ireland Offices. Our objectives will be achieved only if each department makes its appropriate contribution and this in turn, we believe, requires a better degree of co-ordination than presently exists. The fact is of course that housing, leisure, education and other relevant policies have important objectives traditionally associated with them: there is always the danger that this potential contribution to the reduction of health inequalities will receive little attention in departmental decision-making.

9.100 For this reason, we propose recourse to Cabinet Office machinery, in order to ensure that this does not happen. A broadly based programme of work needs to be explicitly adopted, and seen to be adopted. Our analysis is very much within the spirit of the Joint Approach to Social Policy (JASP), and Ministerial and Official Committees corresponding to those established under JASP would provide appropriate fora: we would certainly wish the Central Policy Review Staff to be involved. It would then be for these Committees regularly to consider developments and to propose developments in relevant policies from the perspective of health inequalities. Major initiatory responsibility would be vested in the Department of Health and Social Security, and we envisage the Committees being chaired by a Minister and by a senior DHSS official having major responsibilities for Health and Prevention. They should have before them relevant statistical material, provided by government statisticians, and relating to changes in uptake and provision of relevant services, changes in distributional aspects, and evaluation of policies. New methods of transmitting the information reviewed would have to be adopted, not least because it would need to reach a wider, public audience.

9.101 There would have to be local counterparts of national co-ordinating machinery, and a joint approach to health policies would be necessary at local level to a greater extent than at present. This might take a number of forms – interdepartmental action, for example, to reduce environmental pollution and squalor and redistribute skilled manpower to communities where the risk to health was high, acceleration of joint funding schemes, and the establishment of joint committees for planning and for the monitoring and supervision of hazards to health.

9.102 The need for a joint framework for social policies has been increasingly acknowledged in recent years. Of course, a co-ordinated approach could achieve a variety of objectives. One would be simply to warn central Departments earlier than at present of forthcoming plans of individual departments. Another would be to work out more smoothly than at present the overlapping functions of 2 or more departments (a good example is nursery education and day nurseries – in the interests of child health). But others would include large-scale reallocation of priorities – as by taking a major decision to reduce the rate of expansion in expenditure of one major social service, such as education, and greatly increase the rate of expansion of another, such as health. For this, however, support independent of central administration may be required, as we argue below. We appreciate that there are a wide range of possibilities, and that a joint approach could mean a great deal or very little. But considering that the Government accepted, in the early 1960s, the need for plans for hospitals and for community care and that since then there have been a stream of plans of wider and lesser scope, developments in the co-ordination of social policies, as distinct from the reorganisation of individual services, has been slow. (The progress since the JASP initiative has been traced by Plowden, 1977). No doubt this slowness is attributable to the precedence currently given not only by the Government but by other bodies to economic over social objectives in policy, to a failure to appreciate the interrelatedness of policies but above all to the stultifying effects of public expenditure control which has dominated all attempts of planning during the mid and late 1970s. In the last 15 years social planning has been, for the central government, predominately one of control of public expenditure (Glennerster, H, 1975, Diamond, J. 1975, Glennerster, H. 1976, Heclo and Wildavsky, 1976). It would be wrong to suppose that this form of control could be changed overnight, because it has penetrated administrative practice at every level, or that there will not be financial and institutional constraints on more imaginative social planning. But the formulation of new social objectives by the Government can only be sustained if certain changes are also made in the mechanisms of planning and administration.

A Health Development Council

9.103 Finally, and distinct from this machinery, although with the same objective in mind, we propose the establishment of a Health Development Council. This would be an independent body, with a small staff of seconded civil servants. Strictly its functions would be advisory but the Council would, we recommend, play a key role in social planning. It would be invited to consider and spell out longer term strategies to reduce inequalities of health and improve general family living standards, evaluate progress in relation to this aim, with particular reference to the roles of particular Government and local authority departments and services, marshal a range of outside expertise, consult the public at every stage and play a major part in explaining the need for certain developments. Opportunities should be afforded to it of commenting on, and contributing to, plans, including expenditure programmes, which are to be published by the Government on matters relevant to its concerns.

9.104 Although we are aware of the arguments against proliferation of such standing advisory bodies, we make this proposal for 3 particular reasons. First, the existence of the Council would provide some guarantee that, when initial enthusiasm had abated, the attempt at inter-departmental co-ordination through a Cabinet sub-committee did not “run out of steam”, as some would say happened with the original JASP initiative. Second, by virtue of its public existence such a body could serve both to keep the issue of health inequalities in the public eye, and enlist widespread support. This is essential, and the development of comparable machinery at the local level (perhaps based on existing AHA – Local Authority Joint Consultative Committees) could be invaluable. Third, the Council would be in a position to assist Ministers in formulating longer-term strategies.


9.105 In discussing actions outside the Health Care system which need to be taken to diminish inequalities of health we have been necessarily selective in this chapter. 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 immediately practicable, in political, economic and administrative terms, which will nonetheless, properly maintained, exert a long-term structural effect. And thirdly, we have continued to feel it right to give priority to young children and mothers, disabled people and measures concerned with prevention. 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. Our recommendation here are presented as a modest first step which might be taken towards this objective.

i. As an immediate goal the level of child benefit should be increased to 5 1/2 %. of average gross male industrial earnings, or £5.70 at November 1979 prices.
ii. 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.
iii. The maternity grant should be increased to £100.
iv. We recommend the introduction of an infant care allowance over a 5 year period, beginning with all babies born in the year following a date to be chosen by the Government.

Beyond these initial elements of an anti-poverty strategy, a number of other steps need to be taken.

v. 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.
vi. 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.
vii. 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.
viii. 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.
ix. 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.
X. Local Authority spending on housing improvements under the 1974 Housing Act should be substantially increased.
xi. Local authorities should increasingly be encouraged to widen their responsibilities to provide for all types of housing need which arise in their localities.
xii. Policies directed towards the public and private housing sectors need to be better co-ordinated.
xiii. Special funding, on the lines of joint funding, for health and local 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 service and housing departments.

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

xiv. Greater co-ordination between Government Departments in the administration of health related policies is required, by establishing inter-departmental machinery in the Cabinet Office under a Cabinet subcommittee along the lines of that established under the Joint Approach to Social Policy (JASP), with the Central Policy Review staff also involved. Local counterparts of national co-ordinating bodies also need to be established.
xv. 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 policy to reduce inequalities in health.


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