Black Report Conference Speech by Rt Hon Beverley Hughes

Speech by Rt Hon Beverley Hughes MP Minister for Children, Young People and Families


I am delighted to be here today to discuss an issue of such importance, and one that was constantly a feature of my early House of Commons experience. It is an issue, one that goes to the heart of what fires me up about social injustice and what drove me into politics. I am sure in this room we are all passionate about reducing the difference that who a person’s parents are, makes to their life chances – whether it is how well they do in school, what job they can aspire to or something as fundamental as their health.

I start, then, wanting all individuals to be able to aspire – to think that next year will be better than this, or that their children will do well. This is the basic stuff of what it is to be human. All people should be able to look at the future in this way. The hard fact though, is that we remain a long way from achieving the degree of equality we want: in our education system; in the level of wealth people have when they start their adult lives; in terms of the life chances – across a range of indicators. These inequalities matter – not just for their own sake – but because they are all about each and every person being able to aspire and flourish.

It is in this context that we have set ambitious targets for reducing health inequalities, and when the government made the commitment in 2000 to set national health inequality targets, it was the only government in the world to do so. Yet the recent Department of Health report on the government’s Programme for Action states we have considerable progress still to make. But we have delivered robust objectives based on clear social democratic values, as the report’s authors made clear, provided a very high level of milestones with which to monitor progress.

There is a vital debate about our principles which I welcome. But I think given the ambition of our stated objectives, the more important debate that we should be having today is about how to translate those values into tangible outcomes for people. I want today to talk about the progress we have made across government. And I want to discuss some of the next steps – particularly in the areas of policy I am responsible for as children’s minister.

Cross government action

Of course health, or more specifically health care, was seen as a basic right of citizenship by the founders of the welfare state. We should never grow tiered of repeating what a great achievement the creation of the NHS was. And we should never forget that it was a fundamental principle of equality which underpinned its creation. This is a principle which is as strong today as it was then.

But supporters of the NHS cannot be mindless cheerleaders; we must be critical friends. Progressive politicians have learnt many lessons since Bevan stuffed the consultants’ mouths with gold. They have recognised that as well as being an overwhelming success story, the NHS has failings that we must both recognise and address. After nearly sixty years of the NHS there are still stark differences and inequalities in the health of people in different communities and in different parts of the country.

These inequalities mostly correlate with differences in geography and that is at least in part because of social class and income. In the 1960s and 1970s academics and social scientists, from a starting point of support for the NHS and its values, investigated health inequalities, and found that the mere fact of the existence of the NHS was not enabling working class people to lead healthier and longer lives, in comparison to middle and upper class people. In other words, the middle classes were disproportionately benefiting from the NHS.

Brian Abel Smith, the leading Fabian and LSE academic, wrote in 1984:

“If socialists believed forty years ago that all that was needed to equalise health status between social classes was to remove the money barriers to access to health care, they were seriously mistaken.”

This does not mean that NHS reform is unimportant. Equitable access to high quality health care remains a vital objective. That is why we have not shied away from reforms which seek to make the health care system, and the professionals working in it, much more focused on the patient. Focussed on all patients, regardless of what income bracket they come from. And that is why we have been unapologetic about looking at the role of different providers of healthcare. While resolutely defending the principle that health care will be free at the point of use, the objective should be high quality and accessible care, with patients at the centre of decisions about what and how care is provided.

Patients do not care who is providing their services. And crucially the public want it free at the point of use – they think this is fair. The Tories, we should not forget, fundamentally do not agree. Indeed we must remember that this is one of a number of ways in which there are clear divides between centre-left and right on this issue.

The dismissal of the Black Report was part of a wider rejection of any acceptance of a correlation between poverty, deprivation and health. In the 1980s, ‘poverty’ was a dirty word – airbrushed from official documents. Responsibility was placed entirely on the individual, without reference to housing, environment, occupation, flying in the face of the situation for many people in the real world.

The Labour government has changed all that. Not only do we continue to increase spending on the NHS while simultaneously reforming its dated structures, but we have changed the terms of the debate in relation to the fundamental causes of health inequalities.

As early as 1993, the Leader of the Labour Party John Smith commissioned the Institute for Public Policy Research to produce a report on social justice. The Commission highlighted that health inequalities had persisted into the eighties and nineties. It concluded that “the health gap between social classes, regions, and communities is neither inevitable nor acceptable. Enabling everyone to enjoy the best possible health, and to receive the treatment and care they need, is an important part of a just society.”

Such recognition of the problem was reflected in early action by the government in 1997. The Acheson report into health inequalities resulted in concerted and continuing action across government. The link between poverty and health has been re-established. Poverty – and its potential consequences – is no longer a dirty word: it’s part of discourse about what governments should be doing. Our approach to achieving a healthier population, and tackling the inequalities in health created by the economic system, is now rooted in an understanding of the broader socio-economic causes of ill-health, and the need to tackle them across a range of policy areas and government departments.

In short, our approach to health is not synonymous with our approach to the NHS. It is about rising income and standards of living, housing, public health, changes in diet in schools, access to sport and leisure, working time regulation, better advice on lifestyles and risk-taking behaviour, changes to smoking legislation, improved air quality, better food labelling and so-on and so-on. It is about concerted action across government and detailed, relentless strategies to try and tackle various aspects of inequalities.

As a result, on many measures the health of the most disadvantaged has improved. There have for example been significant improvements in death rates from cancer and heart disease since 1997. Those in disadvantaged areas have not missed out – they have improved outcomes as well. Indeed, there has even been some narrowing of inequality in terms of cancer death rates. We should be proud of this. In other areas though – despite all groups improving – the gap has not narrowed and even widened. This is the case for life expectancy by area and for infant mortality rates across social classes, where improvements for the most disadvantaged, whilst significant, have not been as great as those of other social class groups. And what this shows to me is that whilst improvements in income are a necessary condition for reducing health inequalities, they are not in themselves sufficient. Rises in income have to be related with changes in life style and behaviour in order to maximise the impact on health: in diet; in smoking in sexual health.

Just as we should be proud of our achievements – we should be concerned where inequalities remain. But to have expected dramatic changes since 1997 would be unrealistic. These facts in large part reflect the long-term trend which we have always been clear would be difficult to turn around quickly. What I am confident about though is that we have started to face up to the enormous challenge. We have made significant progress in getting the fundamentals right and investigating a process that is demonstrably now going in the right direction.

I have already mentioned the wider public health agenda – given added impetus by last year’s Choosing Health white paper. But other policy areas are vital too:

We have continued to bring down the levels of poverty – particularly among children – with more than a million children lifted out of poverty since 1997. Our ambition here could not be higher – it is to abolish child poverty by 2020. This will take time to show an impact on health indicators, but ultimately is perhaps the most important of our achievements;

We must also continue to improve the quality of housing – something which the Child Poverty Review recognises as an integral part of our anti-poverty agenda and also something on which inequalities have reduced;

If we continue to deliver on these – and other – agendas then we will turn the health inequality tanker around. As Sir Michael Marmot states in the recent report on the government’s Programme for Action; we should be proud of what can be achieved given strong commitment form all involved. But as Sir Michael also makes clear; we must keep up the pressure.

Children’s Health

That is one reason why I have ensured that children’s health is considered one of my priorities as children’s minister. Across government, we are taking action – getting the fundamentals right – and the early years is no exception.

As many of you will know, we are working hard with local government to achieve a fundamental re-organisation of children’s services. Children’s social services and education trusts are being brought together into new children’s trusts. This will allow the development of comprehensive and integrated support for children and their families. This more tailored support will in turn ensure a relentless focus on improving children’s outcomes, of which health is one vital example.

Many local authorities and PCTs are already working closely on reorganising and commissioning services. The opportunities going forward are significant. Fewer silos. Less Whitehall diktat. And in their place, each locality better able to respond to the needs of parents and children.

A critical measure of success for children’s trusts will be how they improve children’s physical, mental and emotional health. They will play a crucial role – alongside local health services – in improving health outcomes for children, young people and pregnant women as set out in the National Service Framework for Children, Young People and Maternity Services.

We are also placing a clear emphasis on parents playing a major role in helping children and young people make healthy choices. This could be through new extended schools, but perhaps more importantly through involvement in the network of children’s centres being opened around the country. There will be one in every community by 2010 – all part of nothing more than a radical extension of the welfare state into the early years. Already some existing Sure Start children’s centres offer health services, such as health visitors and midwives. They can also give parents advice and support in promoting healthy outcomes for themselves and their children. Our ambition is for this to become the norm.

Taken together Children’s Trusts and Sure Start children’s centres will offer – indeed in some cases already are offering – the opportunity to bring together services for children in new ways. This is not about organising services just as they have always been. It is about focusing relentlessly on children’s outcomes – their life chances – and not shying away from tough questions about what works best.

As in other areas, this will take time to feed through into people’s real lives. Get it right though and this reform will make a vital contribution to reducing health inequalities as well as promoting wider life chances.

So let me conclude. We do have ambitious and clear objectives, that we have made significant progress on. We are getting the fundamentals right. But of course, the struggle for social justice must continue. Many of the problems we are facing up to are deep rooted – they are about action across government, about changing people’s behaviour and about reducing deep-rooted socio-economic disadvantage. Across government we must continue to focus on not just improving outcomes for all but narrowing the inequalities which we believe to be unjust.

Looking around this room I see a lot of faces who share my passion and values.

It is a pleasure to be in such company and I look forward to both the discussion and working with you in the future.

Thank you.

Discussion – following Beverley Hughes’s speech

Questions and Comments

Parents are not getting the help they need – often holding down two or three jobs. Parents and pensioners caring for disabled children aren’t getting help despite saving the government money.

Income for the poorest parents has increased by 20% since 1997. Parental involvement is essential for the health of children: women’s smoking and nutrition or smoky houses.

If the government say they are interested in reducing the inequalities gap, then how do the 4 week quit targets and exemptions proposed in their smoke free policy tie in with this, as both serve to widen the gap?

There’s a lack of link up between young people, schools and GPs.

The PCTs are on board but GP involvement is variable. Children’s targets are swamped.

What about quality of life rather than quantity?

It’s mortality and morbidity. Current health inequalities are unacceptable.

People’s concern about service providers – disillusionment.

Death rates for cancer – artefact of recording? People live longer so could that be why it seems that the death rates are dropping?

Marmot showed that the improvements were not artefact.

Government policy targeted at specific groups. What about the people who fall between services?

We haven’t thought about the inter-generational links between health. Inter-agency working – yes there is a problem and it needs to be addressed.