Health inequalities politics and policy under New Labour
Introduction
I’ll start by setting out some assumptions. The first is that I view health as socially constructed: I can’t assume that everyone here shares this view. I shan’t attempt to define health, as I’m discussing New Labour’s health rather than mine. I will define health inequalities – as unjust or unfair differences in health determinants or outcomes within or between defined populations. In talking about politics, I’m referring to the use of power and authority in the satisfaction of human needs and aspirations. And for the purposes of this discussion, health inequalities policy refers to all public policy that impacts on health inequality, whether that impact is intended or unintended.
It will already be clear that I view definition as crucial; a fair proportion of the controversies within ‘inequalogy’ are semantic rather than substantive. Thus, rather than reverentially espouse the Third Way, I waited patiently for a definition. When it finally came (Blair, 1998) I was delighted with the statement that rooted it in ‘our enduring values of fairness, justice, the equal worth and dignity of all’. This from the leader of the party whose election manifesto had rejected values and ideology in favour of the bland assertion that ‘what counts is what works’. As a recent retrospective piece by the editor of the New-Labour-supported journal Renewal recently stated, ‘within a few years…..Labour had been moved by some elements from a position of sentimental reverence for its past to one of contempt or indifference. The rhetoric of Labour movement almost wholly disappeared, because movement implies progression along some pathway of principle and policy. People were compelled to choose to identify with the past or the present. Paradoxically this had the unintended effect of making the past a much nicer place than it actually was. Roy Hattersley and Tony Benn could both inhabit ‘old Labour’, explicitly or implicitly promoting a ‘golden age’ when Labour leaders really believed in equality. The fact that they did bugger all effective about it could be safely ignored’ (Thompson, 2000).
Having said this, the importance of explicit values in politics should not be underestimated. While it may be unrealistic for New Labour supporters and other social democrats who are, after all, supporters of an ideology predicated on inequality – to meaningfully commit themselves to ultimate equality of outcome, their sincere commitment to ‘caring capitalism’ is unquestionable. In this context, New Labour steers a careful path between values and pragmatism.
New Labour and health inequalities policy
It is not possible in the time available to comprehensively summarise three years of health inequalities policy. Suffice it to say that New Labour surfed into power on a wave of enthusiastic, glittering activism. Health inequalities was no exception – the UK’s first Minister for Public Health, Tessa Jowell, was as strong on the rhetoric of equity as any of her colleagues. Among her first actions were the granting of the ‘freedom to say inequalities’ where her predecessors had permitted only ‘variations’, and the establishment of the Independent Inquiry into Inequalities in Health under Sir Donald Acheson, which had been promised by Chris Smith as Shadow Health Secretary.
The Acheson enquiry (Acheson, 1998) covered enormous ground and made important recommendations but still left much to be desired. Government-imposed constraints resulted in an inability to make costed or fiscally radical recommendations, or to propose national inequality targets to a government whose public health Green Paper had identified the reduction of health inequalities as one of its two key aims. Other omissions were self-inflicted. These included the absence of a definition of inequality, the minimal theoretical analysis, the curious and confused ‘model….used to guide research’ (in fact a model of health rather than of health inequality), and the missing section on research and development. The report prioritised three of its 39 recommendations – relating respectively to health inequalities impact assessment of all relevant policies, the health of families with children, and the further reduction of income inequalities and poverty.
The Government’s response to Acheson (Department of Health, 1999) was embarrassingly minimalist, providing detailed lists of policy actions already taken in the areas covered by Acheson, but no real indication of any explicit response to the Acheson analysis. As Macintyre (1999) points out, the breadth of the listed policy actions ‘means that it is very hard to discern in what ways the Acheson report has had any direct impact on government policy’. In addition, there is no apparent awareness of the distinction between inequality and poverty, nor of the major policy implications of this distinction. The Acheson recommendation on income inequality is ignored.
More constructive criticism has come from other quarters. The authors of the Black report reconvened in order to make detailed policy proposals and to press for ‘a staged programme of the action needing to be taken by different government departments (in response to Acheson)….to be specified by the government’ (Black et al, 1999). Importantly, they also draw attention to the under-researched issue of the contribution of specific policies to health inequalities. An adequate operationalisation of Acheson’s ‘health inequalities impact assessment’ would help here – as indeed it would in relation to the comments of Davey Smith, Dorling, Gordon and Shaw (1999), who draw attention to the failures of both the Acheson report and of Government policy to address adequately the fundamental role of inequalities in material circumstances in determining health inequality. For instance, with regard to one of their many examples – the five-fold difference in access to university between children living in the richest and poorest quarter of areas in Britain – it’s clear that the Government’s decision to introduce higher education fees would have benefited from health inequalities impact assessment.
In general, I think it’s fair to say that despite New Labour’s espousal of a socio-environmental model of health, their awareness of the real meaning of healthy public policy (or rather, health-equitable public policy) is seriously deficient. Suffice it here to exemplify this with the health inequalities implications of globalisation, arms trading, racial and gender discrimination. Important exceptions to this are the Government’s policies on social exclusion – restricted though they are (Prime Minister, 1998) – and their (very) long-term commitment to reducing and ultimately ending child poverty (Secretary of State for Social Security, 1999).
Within the health sector, there has been a plethora of policies explicitly focused on reducing health inequalities. In many cases it seems unclear how this will be achieved. A reading of the evidence base – and the government claims to be committed to evidence-based health policy – would suggest that the Health Action Zones, Health Improvement Programmes, Healthy Living Centres and all the rest will not reduce inequality to the extent that would be achieved by policies focusing directly on material conditions. Within the health sector, examples might include the phased abolition of all NHS charges and all six-figure NHS salaries; if successful, these approaches might be extended throughout the public sector.
Moving on to non-material influences on health inequality, it is arguable that the government’s flirtation with ‘social capital’ is similarly misguided. Rather like the Third Way, social capital has the appearance of a fashionable empty vessel (perhaps in this case a piggy bank?) which can be filled with just about any hypothesised psychosocial determinants of health or quality of life. This in turn gives it the win-win property of being all things to all who use it, especially the economically privileged – or as Labonte (1999) puts it, ‘social capital….allows elites who benefit from economic practices that undermine social cohesion to voice that loss without necessarily linking it back to those practices that privilege them.’ it is surely no coincidence that the World Bank is a major exponent of social capital-ism. Back in the health sector, some commitment to addressing the social relations (especially the massive power inequalities) of health care would be welcome.
Modernising policy
it must be acknowledged that some areas of government thinking are more ‘joined-up’ than others. In parallel with the evident disarray on health inequalities policy, the Modernising Government White Paper (Prime Minister and Minister for the Cabinet Office, 1999) makes sophisticated proposals for improving policy performance. For example, in the health / equity context, the Government is establishing ‘an integrated system of impact assessment and appraisal tools in support of sustainable development, covering impacts on business, the environment, health and the needs of particular groups in society’. Arguably, fulfilling the objectives of the UK Health Equity Group will require going well beyond this – for example, ensuring that health and equity are embedded in all stages of the policy process.
In conclusion
I will conclude this selective review of New Labour’s performance on health inequalities with a quote from Townsend (1999) – a seasoned observer of the achievements and failures of successive governments on health inequalities policy:
‘There is no doubt that the 1997 Labour government is giving greater priority than did the preceding governments of the 1980s and 1990s to inequalities in health. Equally, there is no doubt that a range of measures, including many which are external to healthcare policy, are now in play. This is welcome. But serious questions need to be raised: (i) of the scale of action so far, (ii) of the effective management of the distribution of earnings and of disposable income, (iii) of the adequacy of income and of living standards generally of the many millions of people with no prospect of having paid employment. The new evidence presented (in The Widening Gap) suggests that action has been too limited, that redistribution has not been addressed, and that poverty levels in Britain are far too high for us to expect to see inequalities in health fall.’
Alex Scott-Samuel
EQUAL (Equity in Health Research and Development Unit)
Department of Public Health, University of Liverpool (about 2000)
References
Acheson D (Chairman). Independent inquiry into inequalities in health. Report. London: The Stationery Office, 1998.
Black D, Morris JN, Smith C, Townsend P (1999) Better benefits for health: plan to implement the central recommendation of the Acheson report. BMJ, 318, 724-727.
Blair T. Speech by the Prime Minister on the occasion of the tenth anniversary of the Institute of Public Policy Research, 14th January 1998. London: 10 Downing Street Press Notice.
Davey Smith G, Dorling D, Gordon D, Shaw M (1999) The widening health gap: what are the solutions? Critical Public Health, 9, 151-170.
Department of Health. Reducing health inequalities: an action report. London: Department of Health, 1999.
Labonte R (1999) Social capital and community development: practitioner emptor. Australia and New Zealand Journal of Public Health, 23, 430-433.
Macintyre S (1999) Reducing health inequalities: an action report. Critical Public Health, 9, 347-350.
Prime Minister. Bringing Britain together: a national strategy for neighbourhood renewal. Cm 4045. London: The Stationery Office, 1998.
Prime Minister and Minister for the Cabinet Office. Modernising government. Cm 4310. London: The Stationery Office, 1999.
Secretary of State for Social Security. Opportunity for all – tackling poverty and social exclusion. Cm 4445. London: The Stationery Office, 1999.
Thompson P (2000) Living in the present, haunted by the past: New Labour and Year Zero. Renewal, 8 (1), 1-6.
Townsend P. Foreword. In: Shaw M, Dorling D, Gordon D, Davey Smith G, eds. The widening gap – health inequalities and policy in Britain. Bristol: The Policy Press, 1999, x-xvii.