What have we learned since the Black Report A VIEW FROM THE INSIDE

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What have we learned since the Black Report ? A
VIEW FROM THE INSIDE

• Ray Earwicker
• Health Inequalities Unit
• Department of Health

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Black and Acheson Compared The Problem

• for Black the crude differences in mortality
  rates between the various social classes are
  worrying in 1971 the death rate for adult men
  in social class V was nearly twice that of adult
  men in social class I
• for Acheson by the 1990s (this gap) was almost
  three time higher

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Black and Acheson Compared Terms of Reference

• For Black (April 1977)
• to assemble available information about
  differences in health status among the social
  classes
• to identify possible casual relationshipsand
  assess the implications for policy
• to suggest what further research might be
  initiated

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Black and Acheson Compared Terms of Reference

• For Acheson (July 1997)
• to review the latest available information on
  inequalities in healthand identify trends
• identify priority areas for future policy
  developmentlikely to offer opportunitiesfor
  beneficial, cost effective and affordable
  interventions to reduce health inequalities
• the report will be published

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Black and Acheson Compared The Process of
Inquiry

• Sir Douglas Black appointed a small working group
  Professor J.N. Morris, Dr Cyril Smith, Professor
  Peter Townsend to help carry out this inquiry
• Sir Donald Achesons inquiry was overseen by a
  scientific advisory group of Professor David
  Barker, Dr Jacky Chambers, Professor Hilary
  Graham, Professor Michael Marmot and Dr Margaret
  Whitehead

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Black and Acheson Compared The Findings

• The Black report (August 1980)
• despite 30 years of the NHS expressly committed
  to offering equal care for all, there remains a
  marked class gradient in standards of health
• much of the problem lies outside the scope of
  the NHS
• 37 recommendations

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Black and Acheson Compared The Findings

• The Acheson report (November 1998)
• Over the last 20 years death rates have fallen
  among both men and women and across all social
  groups. However, the difference in rates between
  those at the top and bottom of the social class
  has widened
• The weight of scientific evidence supports a
  socio-economic explanation of health inequalities
  (and)the need to intervene on a broad front
• 39 recommendations

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Black and Acheson Compared Some Differences

• The time allowed for each inquiry
• The international dimension
• The focus of each report particularly around
  the NHS
• The scope of each report dimensions of gender,
  age, ethnicity
• Costings

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Black and Acheson Compared The Reception

• On Black, additional expenditure on (this)
  scaleis quite unrealisticI am making the report
  available for discussion but without any
  commitment by the government to its proposals
• Patrick Jenkin MP, Secretary of State for Health
  (1980)
• On Acheson, Tackling health inequalities has
  been a high priority for the governmentone of
  the first things we did was to commission Sir
  Donald Achesons inquiry
• Yvette Cooper, Minister for Public Health (2001)

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Black and Acheson Compared The Outcome

• The Black report buried without trace ? (like
  the Royal Commission on the NHS)
• The Acheson report still informing policy six
  years after publication
• Yet

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A new political climate

• (We) will attack the root causes of ill
  health(and)set new goals for improving the
  health of the nation which recognises the impact
  that poverty, poor housing (and)
  unemploymenthave on health
• 1997 Labour Party manifesto

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but is it a sufficient condition for action on
health inequalities ?

• Two visions at the heart of government
• incremental, health focused (smoking), emphasis
  on health improvement, local targets, less
  expensive
• strategic, focused on wider determinants as well
  as health, emphasis on health inequalities,
  national targets justice, more expensive

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After Acheson, health inequalities are on the
agenda

• Accepting the social gradient - improvements in
  health mean tackling health inequalities
• Partnership rather than control - joined up
  government means sharing responsibility
• Effective action on the ground addressing the
  wider determinants
• Setting national targets for delivery
• Moving to a health rather than a sickness service
  - the changing role of NHS

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The debate on targets

• is an important area for policy development, we
  were advised that (the setting of targets (for)
  reducing health inequalities) was not within the
  Inquirys remit (Acheson, 1998)
• local targets (will be required) to address
  local priorities and cut health inequality
  (Saving Lives Our Healthier Nation, 1999)
• For the first timethe creation of national
  health inequalities targets (will help) narrow
  the health gap (The NHS Plan, 2000)

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A national target the watershed for health
inequalities

• By 2010, to reduce the inequalities in health
  outcomes by 10 per cent as measured by infant
  mortality and life expectancy at birth
• The national health inequalities PSA target (2002)

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New impetus for action

• Consultation on a plan for delivery (2001)
• Cross cutting review on health inequalities
  (2002)
• Tackling Health Inequalities A Programme for
  Action (2003)
• Securing Good Health for the Population (Wanless
  report 2004)

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Building on the national PSA target

• Objective 1
• To substantially reduce mortality rates by
  2010from (CHD) by at least 40...with a
  reduction of at least a 40 reduction in the
  inequalities gap between the fifth of areas with
  the worst health and deprivation indicators and
  the population as a wholeand from cancer by at
  least 20 with a reduction in the inequalities
  gap of at least 6...
• DH PSA target, 2004

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Building on the national PSA target

• Objective 2 (as before)
• Reduce health inequalities by 10 by 2010 as
  measured by infant mortality and life expectancy
  at birth
• DH PSA target, 2004

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Building on the national PSA target

• Objective 3
• Tackling the underlying determinants of ill
  health and health inequalities by 2010 by
  reducing adult smokingwith a reduction in
  prevalence among routine and manual groups to 26
  or less halting the year on year rise in obesity
  among children under 11reducing the under-18
  conception rate by 50
• DH PSA Target 2004

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A Programme for Action

• A strategic approach that mirrors the Acheson
  report
• Recommendations reflect social gradient
• Action on a broad front across the whole of
  government local regional and national
• Mainstreaming health inequalities, improving
  services
• In for the long term

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A Programme for Action
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Delivering change levers and processes

• Roles and responsibilities
• National co-ordination around PSA targets
• Local partnerships engaging local government
• Performance management National Standards,
  Local Action
• Assessing need Health Equity Audit

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Full circle

• the policies and areas for policy
  development which we have identified from the
  available evidence, comprise an effective agenda.
  Its components are mutually reinforcing(and)
  will make a major beneficial impact on
  inequalities in health. We hope that it will
  also provide a sound basis for policy development
  well into the next millennium.
• Preface to the Acheson report (1998)