More equality - just what the doctor ordered

Health is not only a matter for the NHS - it reflects housing, unemployment, poverty. Labour is revisiting the Black report of 1980, which aimed to reduce inequalities which condemn the poor to bad health, says Jeremy Laurance
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The Independent Online
Tessa Jowell learnt a new phrase last week: the "food desert". Food deserts, the minister of public health was told at a private seminar in London, are those areas of inner cities where cheap, nutritious food is virtually unobtainable. Car-less residents, unable to reach out-of- town supermarkets, depend on the corner shop where prices are high, products are processed and fresh fruit and vegetables poor or non-existent.

It was part of the new minister's preparation for a major speech next month in which she will set out the Government's plans on public health. Among them is an idea that would, if backed with sufficient political clout, go beyond anything the Government has so far pledged. It could even change the way we think about health matters.

It is not that the Government's early initiatives have lacked impact. The ban on tobacco advertising and sports sponsorship was dramatic and courageous. The promised cuts in NHS paperwork to deliver pounds 100m of savings may be less than a day's revenue for the NHS but an extra pounds 10m here and there, such as that allocated to breast cancer services, can cut waiting times and reduce anxiety. Moves to abolish the NHS internal market may happen more slowly than some hoped, but it is almost certainly wise to allow time for alternative arrangements to be piloted.

But this is small beer compared to Labour's big idea. Frank Dobson and his team may not succeed in changing much in the NHS - and may end up not wanting to when the results of studies they have launched come in - which means that they need to look to the arena of public health for a fresh approach. They have chosen to re-visit the 1980 Black report on inequalities in health and set about reducing the health divide between the poor and the rich.

Such an enterprise, if it led to action, could do more than improve the lot of the poor. Commissioned by the last Labour government, Sir Douglas Black, the eminent physician who later became president of the Royal College of Physicians, recognised that health could not be compartmentalised. His report made clear that measures affecting schools, transport, housing, employment and poverty all affect health. A review of the Black report would have implications across government departments - and it is their agreement to its precise terms that is still awaited.

The original report - a well-thumbed copy of which was produced by Frank Dobson on his first weekend in the health department - made wide-ranging recommendations on how to reduce inequalities in health. Among them was a costly proposal - one of many - to tackle child poverty with a sharp increase in child benefit. The total cost of its proposals was put at pounds 2bn at 1979 prices (equivalent to pounds 5.4bn today) with no clear evidence that they would succeed in reducing the health divide.

The Tory government which inherited the report quietly buried it - there was no press conference and only 260 cyclostyled copies were ever printed - but it is unlikely even a Labour government would have found the means to implement it.

New Labour, however, believes there may be a new way of approaching it. At the Royal College of Nursing's annual conference in Harrogate last month, Frank Dobson floated the idea of a new soundbite for the next election - "vote Labour, live longer" - and won a standing ovation from 1,500 nurses despite his grim warning on pay. Reducing inequalities, promoting social justice and restoring fairness has been a recurring theme in health ministers' speeches. In Mr Dobson we have a serious, old Labour commitment to tackling injustice and in Ms Jowell, one of Tony Blair's golden wunderkind, a reflection of the new spirit of the socially conscious times.

Ms Jowell, 49, the daughter of a doctor, is fond of citing the statistic which shows that a child born today into social class I (professionals) will on average live seven years longer than one born into social class V (manual workers). While death rates among social class V have remained unchanged over the past 70 years, among those in social class I they have halved. The poor have always died younger than the rich but the gap is widening.

Her appointment as public health minister raised hopes that the new government would look beyond the NHS to improve the nation's health. Ms Jowell, following an initiative by Chris Smith, Labour's health secretary until the election, when he was moved to the heritage department, has now asked Sir Donald Acheson, former government chief medical officer, if he would update the Black report. He has submitted draft terms for a review and is awaiting the go-ahead.

Publication of an updated Black report would be an apt way for the Labour government to mark the NHS's 50th anniversary which falls in July next year - if such a deadline could be met. Sir Donald is known to believe that by focusing on certain "points of intervention", such as in pregnancy and infancy, measures could be taken to alleviate the health disadvantages that the poor suffer.

Reviving the Black report is an idea that holds strong appeal for Frank Dobson and Tessa Jowell, who both represent deprived inner London constituencies. Their commitment is shared by the current chief medical officer, Sir Kenneth Calman, who took a calculated political risk by addressing a conference on poverty and ill health weeks before the election in which he highlighted the problem of student poverty.

A serious examination of health inequalities and the measures needed to reduce them could alter the way we think about health. Shifting the focus from the process - the treatments that doctors provide - to the outcomes - the number of lives saved or improved - would remind us that the main influences on health lie outside the ambit of medicine and include housing, employment and poverty. The effect would be to displace the NHS from its central role in health care to become one organisation among many - including government departments, local authorities, schools, employers - with a role to play in improving health.

The process was begun by the Tory government's Health of the Nation strategy, launched in 1992, which set 27 health targets to be achieved between 1994 and 2005. However, the strategy was fatally undermined in the view of many experts by its failure to acknowledge the impact of poverty. Re-targeting the strategy on the social class-based health divide could, if pursued with sufficient vigour, make the Tory NHS reforms seem like a minor management review.

Adoption of such a strategy would have a further virtue. It would raise a vital question about the NHS - whether all it does is worth doing. The focus on numbers of patients treated, beds occupied and operations performed which has dominated debate about health for the past 18 years could give way to a more mature consideration of the benefits treatment brings. Securing the future of the NHS is only a part of the task of protecting the nation's health.

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