Whatever Happened to the Black Report?

The Black Report is not the first or last public health publication where the description of problems is more impressive than the proposed solutions.  The report made 37 recommendations for action.  Much has changed in the last 25 years, but this article written in 2005 attempts to establish what, if anything, has happened in respect of each of them.  The recommendations have been edited slightly.

 1 School health statistics should routinely provide, in relation to occupational class, the results of tests of hearing, vision, and measures of height and weight. Although data is collected about babies and breast feeding in relation to social class there does not appear to be comprehensive data about hearing, vision, height or weight.  Consensus appears to be that routine monitoring of the whole population is not cost effective.  School nurses are beginning to make a comeback, but are likely to be more focussed on children with problems and less on monitoring. It may be time to revisit the costs and benefits of routine monitoring of all children.  Perhaps information about the physical condition of pupils in the school could be correlated with academic achievement.
 2 Representatives of appropriate government departments should consider how progress might rapidly be made in improving the information on accidents to children. Information seems to be much better.  It is well established for example that children in the lowest socio-economic group are over 4 times more likely to be killed as pedestrians than their counterparts in the highest socio-economic group. In Wales there is an almost comprehensive system for collecting accident data including on children from all A&E departments – a source of much useful information and a database for much epidemiological research.
 3 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. The HEC bit the dust a long time ago.  England had a National Task Force on Accidental Injury and  The Child Accident Prevention Trustwas established in 1981. One of the key health targets established in 1999 is to reduce the death rates from accidents by at least one fifth and to reduce the rate of serious injury from accidents by at least one tenth by 2010
 4 Consideration be given to development of the National Food Survey into a more effective instrument of nutritional surveillance in relation to health through which various at risk groups could also be identified and studied. The National Food Survey seems to have been taken over by the Food Standards Agency and become the National Diet & Nutrition Survey.
 5 In the General Household Survey steps should be taken to develop a more comprehensive measure of income, or command over resources, through either (a) a means of modifying such a measure with estimates of total wealth or at least some of the more prevalent forms of wealth. such as housing and savings or (b) the integration of income and wealth, employing a method of, for example, annuitization. The General Household Survey continues to cover income, but measures of wealth are notoriously difficult in every sense.
 6 The importance of the problem of social inequalities in health and their causes as an area for further research needs to be emphasized. The Health Variations Programme was a research programme focused on the social determinants of health inequalities funded by the Economic and Social Research Council from 1996 to 2001. It was followed by the Acheson report in 1998.
 7 Resources within the National Health Service and the Personal Social Services should be shifted more sharply than so far accomplished towards community care particularly towards ante-natal, postnatal and child health services, and home help and nursing services for disabled people. We see this as an important part of a strategy to break the links between social class or poverty and health. This still seems like a good idea and governments of all flavours have pledged to do it. Progress in achieving these shifts has been minimal because of the immense power of hospitals to attract funds.
 8 The professional associations as well as the Secretary of State and the Health Authorities should accept responsibility for making improvements in the quality and geographical coverage of general practice, especially in areas of high prevalence of ill-health and poor social conditions. Where the number or scope of work of general practitioners is inadequate in such areas we recommend Health Authorities to deploy or redeploy an above-average number of community nurses attached where possible to family practice. The distribution of general practitioners should be related not only to population but to medical need. Distribution of GPs in poor areas has not improved very  much, although the various schemes for salaried GPs and PMS seem to be potentially a more effective mechanism for effective action than previous efforts.
 9 We recommend that the resources to be allocated should be based upon the future planned share for different services including a higher share for community health. Funding arrangements have changed, but despite widespread agreement that community health is effective and needs more resources there is little evidence that the proportion of expenditure absorbed by hospitals has fallen.
 10 A non-means-tested scheme for free milk should now be introduced beginning with couples with their first infant child and infant children in large families. Milk went through a bad time because of its high fat content.  Resources are going towards fruit in schools, although milk is still available for poor families. It has recently been rehabilitated and milk is being provided free of charge to all children in some schools as a result of the cheap EU scheme.
 11 Areas and districts should review the accessibility and facilities of all ante-natal and child health clinics in their areas and take steps to increase utilisation by mothers, particularly in the early months of pregnancy. There has been very little work done in this area in the last 25 years. Rachel Rowe and Jo Garcia and their team carried out an interesting project in 2003.(The innovative work of Boddy et al in the Grassmarket in Edinburgh aimed at making antenatal care accessible to deprived populations does not seem to have been replicated widely which is a pity).
 12 Savings from the current decline in the school population should be used to finance new services for children under 5. A statutory obligation should be placed on local authorities to ensure adequate day-care in their area for children under 5 and a minimum number of places the number being raised after regular intervals should be laid down centrally. Further steps should be taken to reorganise day nurseries and nursery schools so that both meet the needs of children for education and care. Surestart was one of the Labour government’s major successes.  It seems to work at least partly because it departs completely from the top down prescriptive approach recommended by Black, but it is on the way to achieving the same results.  Part-time education is available for all 3 and 4 year olds for 12.5 hours at present and this is planned to rise to 20 hours a week. More than half a million childcare places have been created.
 13 Every opportunity should be taken to link revitalised school health care with general practice and intensify surveillance and follow up both in areas of special need and for certain types of family. The evolution of Children’s Trusts is intended to produce more integrated and responsive services.
 14 An assessment which determines severity of disablement should be adopted as a guide to health and personal social service priorities of the individual and this should be related to the limitation of activities rather than loss of faculty or type of handicap There has been some progress in joint assessment and in considering limitation of activities both in health and in Social Security.
 15 A Working Group should be set up to consider:i. the present functions and structure of hospital residential and domiciliary care for the disabled elderly in relation to their needs in order to determine the best and most economical balance of future services;and ii. whether sheltered housing should be a responsibility of social services or of housing departments and to make recommendations; There has been a long debate about long term care for the disabled elderly. Few long term wards remain in hospitals.  Sheltered housing is now provided mostly by housing associations.Extra care sheltered housing is the new model which has the potential to significantly improve the community care of the elderly and the elderly disabled.  There is still debate around the future of “Supporting people”, which is likely to restrict funds to the most needy.
 16 Joint funding should be developed and further funding of a more specific kind should be introduced if necessary within the exist the existing NHS budget, to encourage joint care programmes. A further sum should be reserved for payment to authorities putting forward joint programmes to give continuing care to disabled people – for example post-hospital follow-up schemes, pre-hospital support schemes for families. and support programmes for the severely incapacitated and terminally ill. Joint work between health and social services has become more common, even though joint funding as known in 1980 is now uncommon. There has been substantial investment in intermediate care. Support for disabled and terminally ill  people often comes from voluntary organisations and hospices.
 17 Criteria for admission to or continuing residence in residential care should be agreed between the DHSS and the local authority associations, and steps taken to encourage rehabilitation and in particular to prevent homeless elderly people from being offered accommodation only in residential homes. Priority should be given to expansion of domiciliary care for those who are severely disabled in their own homes. This is a battle largely won.  All parties now advocate helping people to remain in their own homes as long as possible, even though this is sometimes difficult.  The residential home industry is declining.Extra care sheltered housing is a breakthrough here as is the new focus on intermediate care. However, generally speaking rehabilitation remains very much the Cinderella element of the NHS even though its importance was recognised by Beveridge himself in his blueprint for the NHS.
 18 The functions of home helps should be extended to permit a lot more work on behalf of disabled people; short courses of training, specialisation of functions and the availability of mini-bus transport, especially to day centres. should be encouraged. Role enlargement in home care is recognised as important in supporting disabled people in their own homes; and is being increasingly practised.  More significant, and not envisaged by Black, is the development of Direct Payments, enabling disabled people to decide for themselves what help they need.
 19 National health goals should be established and stated by government after wide consultation and debate. Measures that might encourage the desirable changes in people’s diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies. The Public Service Agreement targets specifically address inequalities in mortality and life expectancy. Measures to reduce smoking and improve diet are shortly to be implemented.  There has been very little agreement about measures to increase exercise or reduce drinking.
 20 An enlarged programme of health education should be sponsored by the Government. and necessary arrangements made for optimal use of the mass media especially television. Health education in schools should become the joint responsibility of LEAs and health authorities. Health education was been out of favour, but seems to have been rediscovered in the White Paper Choosing Health. Health promotion / education in schools is the joint responsibility of LEAs and PCAs and is seen as very important in achieving sustained lifestyle change.
 21 Stronger measures should be adopted to reduce cigarette smoking. These would include:
a. legislation rapidly to phase out all advertising of tobacco products (except at place of purchase); Now achieved
b. sponsorship of sporting and artistic activities by tobacco companies should be banned over a period of a few years. and meanwhile there should be stricter control of advertisement through sponsorship; To come into effect, finally, this year.
c. regular annual increases in duty on cigarettes in line with rises in income should be imposed to ensure lower consumption; Was implemented but further increases are inhibited by the threat of smuggling from lower duty areas.  Needs to be tackled on a Europe wide basis.
d. tobacco companies should be required to submit plans in consultation with Trades Unions for the diversification of their products over a period of 10 years with a view to the eventual phasing out of sales of harmful tobacco products at home and abroad; Tobacco companies did not embrace this suggestion.
e. a stronger well presented warning should appear on all cigarette-packets and such advertisements as remain. together with information on the harmful constituents of cigarettes; Has been implemented, and further gory illustrations are about to be introduced.
f. the provision of non-smoking areas in public places should steadily be extended, and To be implemented in government buildings in 2006 and in everywhere except pubs without food in 2008
g. a counseling service should be made available in all health districts. and experiment encouraged in methods to help people reduce cigarette smoking. Extensive investment in smoking cessation, and particularly in nicotine replacement therapy.
 22 In the light of the present state of knowledge we recommend that screening for neural tube defects (especially in high risk areas) and Down’s Syndrome on the one hand, and for severe hypertension in adults on the other should be made generally available. Screening is much more widely available – although there are still doubts about the cost and benefits.Screening for neural tube defects and Downs Syndrome is now routine and well attested. Widespread use of folic acid is also reducing neural tube defects. Screening for severe hypertension is more or less practised by General Practitioners now on their practice populations
 23 We recommend that the Government should finance a special health and social development programme in a small number of selected areas, costing about £30m in 1981-82. Health Action Zones by another name? Targetted funding – Neighbourhood renewal etc. – is now one of the major programmes for tackling inequalities.  This approach is open to the criticism that inequalities within areas are as significant as inequalities between areas.
 24 As an immediate goal the level of child benefit should be increased to 5½% of average gross male earnings or £5.70 at November 1979 prices. Increasing Child Benefit was one of the first acts of the Blair government in 1997.  Now £17 per week for the first child and £11.40 for other children, although this is only about 3.5% of average gross male earnings.
 25 Larger child benefits should be progressively introduced for older children after further examination of the needs of children and consideration of the practice in some other countries. Child Tax Credits play this role, but are means tested.
 26 The maternity grant should be increased to £100. The universal maternity grant has been abolished, but the Sure Start Maternity Grant, which is means tested, is now £500. Paid maternity leave is now worth about £1400, and there are proposals to increase it next year.
 27 An infant care allowance should be introduced over a 5 year period beginning with all babies born in a year following a date to be chosen by the government. No progress on this, although rates  for young children in means tested benefits were increased very significantly by the first Blair government.
 28 Provision of meals at school should be regarded as a right. Representatives of local authorities and community dieticians should be invited to meet representatives of parents and teachers of particular schools at regular intervals during the year to seek agreement to the provision and quality of meals. Meals in schools should be provided without charge. Jamie Oliver is working on this one, and there is a campaign, particularly in Scotland, for universal free school meals – which are already available in Hull.
 29 A comprehensive disablement allowance for people of all ages should be introduced by stages at the earliest possible date beginning with people with 100 per cent disablement. Disability Living Allowance was introduced in 1992 with this intention, although it does not assess disability with a percentage system.
 30 Representatives of the DHSS and DE, HSE, together with representatives of the Trade Unions and CBI should draw up minimally acceptable and desirable conditions of work. The Labour Government introduced the minimum wage, and the EU has laid down rules about hours of work and holidays but neither has been inclined to get involved in details about acceptable conditions of work.
 31 Government Departments, employers and unions should devote more attention to preventive health through work organisation, conditions and amenities. and in other ways. There should be a similar shift of emphasis in the work and functions of the Health and Safety Commission and Executive and the Employment Medical Advisory Service. The workplace as a key setting for health promotion is now recognised including in the English Public Health White Paper. And HSE is increasingly interested in wellbeing at work as well as the traditional health and safety issues. Stress at work is HSE’s current top priority for action. Unions are still demanding action on Corporate Manslaughter.
 32 Local Authority spending on housing improvements under the 1974 Housing Act should be substantially increased It fell.  Housing is an area where government intervention has considerably reduced, although the imposition of the Decent Homes Standard has made a considerable impact on the living conditions in social housing.
 33 Local authorities should increasingly be encouraged to widen their responsibilities to provide for all types of housing need which arise in their localities. Local Authorities now have a strategic role in housing and look at all local needs in their Housing Strategies. But they no longer build houses.
 34 Policies directed towards the public and private housing sectors need to be better coordinated. The intention is clearly to reduce further the role of local authorities in the provision and management of housing.  In the more mixed housing economy there is better co-ordination in some places, especially in regeneration areas
 35 Special funding on the lines of joint funding for health and 1oca1 authorities should be developed by the Government to encourage better Planning and management of housing, including adaptations and provision of necessary facilities and services for disabled people of all ages by social services and housing departments. Joint funding as it was has gone, but pooled budgets and cross-sector working are at last becoming widespread, especially in respect of disabled people, mental health and children’s services.
 36 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 sub-committee along the lines of that established under the Joint Approach to Social Policy with the Central Policy Review staff also involved. Local counterparts of national coordinating bodies also need to be established. There is a Cabinet committee on Public Health, but reports of its activity are sparse. Having a Minister for Public Health is a small step in this direction but might be more effective if of cabinet rank.  Still little articulation at the highest level that everything that central government does impacts directly or indirectly on health and wellbeing. There are now plenty  of local co-ordinating bodies, but the centre is lagging behind.
 37 A Health Development Council should be established with an independent membership to play a key advisory and Planning role in relation to a collaborative national policy to reduce inequalities in health. We had a Health Development Agency – just amalgamated withNICE.  And we do have policies to reduce inequalities in health.