Title: What have we learned since the Black Report A VIEW FROM THE INSIDE
1What have we learned since the Black Report ? A
VIEW FROM THE INSIDE
- Ray Earwicker
- Health Inequalities Unit
- Department of Health
2Black 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
3Black 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
4Black 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
5Black 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
6Black 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
7Black 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
8Black 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
9Black 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)
10Black 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
11A 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
12but 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
13After 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
14The 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)
15A 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)
16New 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)
17Building 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
18Building 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
19Building 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
20A 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
21A Programme for Action
22Delivering 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
23Full 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)