http://bmj.bmjjournals.com/cgi/content/full/331/7516/575
BMJ 2005;331:575 (10 September),
Letter
Labour's "Black report" moment?
EDITOR - The release of the government's latest report on health
inequalities on 11 August was curious.1 2 Reminiscent of the covert release
of the Black report on August bank holiday in 1980, the report appeared
when the minister for public health was on holiday and her deputy
unavailable.
Personal trainers
In July 2003 the government stated that there would be an annual report
from the Department of Health on health inequality indicators related to
the health inequality targets. Nothing appeared for more than two years,
although the data that were eventually released had been available for some
time,3 and when they did appear it was, conveniently, after the election.
Even stranger, the press release for the latest report deflected attention
from the key finding of widening inequalities in life expectancy and infant
mortality by headlining the 12 "early adopter sites" with their "health
trainers."4 The minister said, "Many people have difficulty in changing to
a healthier way of life... Health trainers are one of the many initiatives
in the white paper which will help narrow this gap by supporting people to
make healthier choices in their daily lives."4
To Labour traditionalists, opposed to victim blaming approaches to health
promotion, this may have triggered memories of Conservative minister Edwina
Currie admonishing the poor to buy cheap but healthy food. To New Labour,
however, it may be grist to the mill.
Shifting goal posts
The circumstances of the release of the report should not be allowed to
detract from its main message—that health inequalities, as measured by both
spatial differences in life expectancy and socioeconomic differences in
infant mortality, have widened. The latest data for life expectancy
(2001-3) show that the gap between England as a whole and the fifth of
local authorities with the lowest life expectancy has increased, by 2% for
males and by 5% for females.
The assessment of trends in health inequalities has not been helped by
targets that have had their spatial and social units altered, start dates
shifted, and measures changed repeatedly in their short lives. The life
expectancy target first mentioned health authorities (which were soon
abolished), then the fifth of local authorities with the lowest life
expectancy, and now a "spearhead" group. Curiously, the 12 early adopter
sites with their health trainers overlap with (but are not exclusively
drawn from) the spearhead group. The spearhead group will (for now) be used
to measure progress towards the life expectancy target.
The infant mortality target has likewise been reformulated, as the official
measure of social class has changed. Moreover, neither of the targets is a
true health inequalities target as they compare the worst off groups with
the average for the population as a whole rather than considering the
entire distribution.3 Indeed, the rapid moving of goal posts seems to have
confused the drafters of this report, with 2001, 2002, and 2003 all being
described as start dates. In fact, New Labour's health inequality targets
were announced in July 2000 in the NHS plan and formalised in February
2001.5 6
Widening inequalities
In opposition Labour consistently promised to implement the recommendations
of the Black report and was incensed by the attempt to cover it up 25 years
ago, as well as by the similar attempt to suppress the impact of the
follow-up report in 1987.7
The hushed up release of this report raises fears that the bold statements
and unprecedented promises of Labour's first years in power—for example,
the pledge to eradicate child poverty within a generation—have now been
wholly over-taken by the individualistic rhetoric of behavioural prevention
and "choosing health" and its three principles of "informed choice,
personalisation, and working together." The linking of the adverse trends
in health inequalities with the introduction of health trainers is a prime
example of this.
Although the proportion of children living in low income households is a
national indicator, the report nowhere mentions measuring, let alone
directly tackling, the static or widening inequalities in income and wealth
that New Labour has presided over, widening housing wealth inequalities
being a prime example.8 Perhaps rather than focusing on changing the health
choices of millions of people the government should think more about a
healthier way to govern and at last choose to use the tax and benefit
systems to kerb growing social inequalities in income and wealth.
Mary Shaw, reader in medical sociology
Department of Social Medicine, University of Bristol, Bristol BS8 2PR
Danny Dorling, professor of human geography
Department of Geography, University of Sheffield, Sheffield S10 2TN
Richard Mitchell, associate director
Research Unit in Health, Behaviour and Change, University of Edinburgh
Medical School, Edinburgh EH8 9AG
George Davey Smith, professor of clinical epidemiology
Department of Social Medicine, University of Bristol
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The complete version of this letter is available at
http://bmj.bmjjournals.com/cgi/eletters/331/7514/419#115362
MS is funded by the South West Public Health Observatory, RM by the Chief
Scientist Office of the Scottish Executive Health Department (SEHD). The
views expressed here are those of the authors, not of their respective
institutions or funders.
Competing interests: None declared.
References
Department of Health. Tackling health inequalities: status report on the
programme for action.
www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4117696&chk=OXFbWI
(accessed 1 Sep 2005).
Dyer O. Disparities in health widen between rich and poor in England. BMJ
2005;331: 419. (20-27 August.)[Free Full Text]
Shaw M, Dorling D, Gordon D, Davey Smith G. Health inequalities and New
Labour: how the promises compare with real progress. BMJ 2005;330:
1016-21.[Free Full Text]
Department of Health. Health trainers for disadvantaged areas. Press
release, 11 Aug 2005. (2005/0285.)
www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleases
Notices/fs/en?CONTENT_ID=4117720&chk=j8T/Dk (accessed 1 Sep 2005).
The NHS plan: a plan for investment, a plan for reform. London: HMSO, 2000.
Department of Health. Health inequalities—national targets on infant
mortality and life expectancy—technical briefing. Revised 2002.
www.dh.gov.uk/assetRoot/04/07/78/96/04077896.pdf (accessed 1 Sep 2005).
Berridge V, ed. The Black report and the health divide. Cont Br Hist
2002;16: 131-71.
Shelter. The great divide: an analysis of housing inequality. London:
Shelter, 2005.
Related Articles
Disparities in health widen between rich and poor in England
Owen Dyer
BMJ 2005 331: 419. [Extract] [Full Text]
Health inequalities and New Labour: how the promises compare with real
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Mary Shaw, George Davey Smith, and Danny Dorling
BMJ 2005 330: 1016-1021. [Extract] [Full Text]
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