Select Committee on Health Minutes of Evidence



Examination of witnesses (Questions 99 - 119)

THURSDAY 16 NOVEMBER 2000

SIR DONALD ACHESON, SIR MICHAEL MARMOT and PROFESSOR MARGARET WHITEHEAD

Chairman

  99. Good morning. May I welcome you to this session of the Committee in our inquiry into public health and particularly welcome our witnesses and thank each of you for coming along today. May I ask you each to introduce yourself briefly to the Committee?
  (Sir Donald Acheson) Donald Acheson, Professor of Epidemiology in the UCL department in London.
  (Professor Whitehead) Margaret Whitehead, Professor of Public Health at the University of Liverpool.
  (Sir Michael Marmot) Michael Marmot, Professor of Epidemiology and Public Health and Director of the International Centre for Health and Society at University College London.

  100. May I begin by asking you a question which has personally concerned me for some time? I recall the public health function being moved from local government in 1974. On reflection, and you have been around actively concerned with public health for all this period, do you feel that was a positive move, do you feel perhaps on reflection that it was a negative move? Clearly you were involved in establishing the new Directors of Public Health in the health authorities subsequent to that. Could you say whether that was a move directly related to concerns over the wider approach we were taking at that point to public health?
  (Sir Donald Acheson) There were two occasions. The first occasion was in 1974 when a reorganisation of the Health Service took public health away from the local authority. Then in 1988 the Government, when I was Chief Medical Officer, invited me to review the public health function, which I did and the report was published, at which stage I took the view, and my colleagues who were with me, that it was best for public health to remain with the health authority and not go back to the local authority. I think my reflection today is that each time there is a reorganisation which changes somebody's contract, a huge number of people take early retirement and are lost; almost everybody over 50 or 55 takes early retirement. This has happened repeatedly in the last 40 years and it is a point which has to be taken into account. The other point is that my own view is that the proper place for public health continues to be with the health authority because that is the place where it is the prime business, whereas in the local authority it is one of many things and may not get the priority it deserves.

  101. I recall, working in a local authority with a medical officer of health prior to 1974 and as a very young councillor being on the public health committee. What I remember very vividly was the way in which the medical officer had a very important role in addressing the health implications of wider local government policy in a range of responsibilities within that local authority. Even though we had a public health committee his remit was way beyond what came within that committee. He was influential in respect of housing, a whole range of areas. It certainly struck me that we appeared to lose some direction on public health when that function left local government. I am very much aware of the way in which in recent times the directors of public health locally have linked in with local authorities, quite rightly. It just strikes me that we have lost a great deal of thrust in terms of progress on public health by virtue of that change in 1974. With respect, you did not quite answer my question as to whether it was a good thing or a bad thing in 1974. I take your point entirely about what happens with a reorganisation, because I have been through a few and I would accept your description. Looking back on it, would you not accept that we lost some energy in public health by removing the old MOH from that function?
  (Sir Donald Acheson) Yes, something was lost but I also think something was gained in putting it with the National Health Service. To me today perhaps more than then, the National Health Service, without any responsibility for health promotion and prevention would be a very strange animal and would in itself, concentrating only on clinical work achievement, be much less than it should be. It is a judgement.

  102. I have concentrated up to the present with my questions on the local arrangements. In relation to the national arrangements we have a Minister of Public Health based within the Department of Health. She was quoted a little while ago as arguing that it would have been ridiculous to remove that public health function, her role, from the Department of Health. We have certainly had evidence from a number of witnesses to this inquiry which suggests that as well as that role being, I shall not say devalued because I know the Minister well and I respect her very much, but the actual status of the public health ministerial role was changed from Minister of State to Parliamentary Under-Secretary, as well as that change which has taken place recently, we have had a lot of arguments that that role must be a much more wide-ranging role and it is wrongly located within the Department of Health. You have had lengthy experience of being within that Department, you have addressed directly the difficulties of working across other Government departments. Do you feel that there is an argument for shifting that role to a model like the Social Exclusion Unit, to somewhere like the Cabinet Office, a free-ranging role and empowering that Minister more than is the case at the present time, to address public health issues across departments?
  (Sir Donald Acheson) The first thing I might say is that I feel it was very much a mistake to reduce the status of the Minister for Public Health from a Minister of State to an Under-Secretary. That was most unfortunate. Whatever else is done, I think that should be put right. On the other issue, what is certain is that if one accepts the socio-economic model of health, which is now very widely accepted, that health depends not only on health services, but education, employment, the environment, public transport and income, then very few of those things, apart from the health services, are within the remit of the Secretary of State for Health. What should we do about that? One alternative would be to have a Minister in the Cabinet Office who would be accountable to the Prime Minister, presumably for public health. This would make the Health Department look very peculiar. The other possibility is to retain it as it is with an increased status but to have a very strong interest within the Cabinet Office in respect of the other important issues to do with health such as I have mentioned. The key frankly is the extent to which the Prime Minister accepts the cross-government roots of ill health. If he or she accepts it, then I am not sure that you need another Minister in the Cabinet Office because quite recently, within the last two days, I received a paper which I hope you and your colleagues have received, Health and Wellbeing: Cross Government Action to Support our Healthier Nation. It is a 34-page document with a very large number of new initiatives which have been taken right across government to reduce inequalities in health. Somehow at the moment it is working, it seems to me, from the Social Exclusion Unit, but that depends very much on the interests of the Prime Minister.

Dr Brand

  103. I was very interested in your reply because in a way it illustrates that perhaps our description of public health covers a very wide field. I have tried to analyse this and there is the sort of anorak function for a director of public health which is to do with communicable diseases and to be really right about disease prevention. Then there is the visionary role of improving people's social wellbeing, their employment, their housing, transport, education and linking all those roles. Do you think one of the problems we have at the moment in struggling with where public health lies, is that we are actually giving two quite separate functions to a public health department? Would it not be more healthy if we could strip off the medical model dominated bit of public health and leave that with the Department of Health and with health authorities, but recognise that there is this wider agenda which has largely been taken over by the Social Exclusion Unit, which I think is probably the better description of what public health should be about, or the promotion of public health but that that should sit more comfortably with either local authorities or the Cabinet Office or indeed the Department of the Environment, Transport and the Regions?
  (Sir Donald Acheson) I am not sure I have much to add to what I said before. I think it is highly desirable that there should be a public health function associated with the National Health Service; I have no doubt about that.

  104. Do you mean the anorak side or the visionary side? I am not being rude about anoraks. We all need people who are careful, obsessional and do the right thing. The world would be a dreadful place if we only had people who had thoughts and never actually did anything.
  (Sir Donald Acheson) The Director of Public Health at the moment has far more than an anorak function. He is not only about in showery weather, he is related to health promotion, immunisation and a huge range of things which are related to a population at risk. So I do not think it is just an anorak. I do feel that there is something to build on in relation to the work of the social exclusion unit, which in the last few days I have only realised is going far beyond social exclusion and being involved in a wide range of projects, as you have seen. The issue is whether you need to have a Minister there in addition to a Minister in the Health Department. As long as you have a Prime Minister who so obviously is engaged in this, I do not think it is necessary.

Dr Stoate

  105. What do you feel are the most significant current trends about health inequalities in terms of things like social class, ethnicity, geographical location and gender, the current most challenging areas in inequality?
  (Sir Donald Acheson) Unquestionably over the last 20 years health inequalities have either remained or increased during a period when mortality on average has fallen shall we say by one third, in other words quite considerably on average. In men, in 1972 the difference in life expectancy between professional people and labourers was 5.5 years and this has now increased to 9.5 years.

  106. Do you mean at birth?
  (Sir Donald Acheson) Yes. You can trace this also through the whole lifecycle from infant mortality right up to expectation of life for people over 60. There are considerable differences and they have increased. In women it has increased from 5.3 years to 6.4 years. The increase from 5.5 years to 9.5 years in men is quite extraordinary.

  107. When did this happen?
  (Sir Donald Acheson) Some of the relevant events probably happened 10 or 20 years ago. It is not due to sudden deterioration. Some of the things which happened like, for example, smoking, project the ill effect on health and mortality up to 20 years after you start smoking or stop smoking. It has not all happened in the last few months. In terms of ill health, recent studies have also shown gradients with socio-economic status for long-standing illness among men and women of all ages and among children, for accidents in men, for anxiety, depression, high blood pressure and overweight in women and also in smoking. The less well off have diets which are less rich in the key protective nutrients such as are contained in fresh fruit and vegetables which protect people against cancer. Right across the board from mortality, morbidity to the risk factors, there are steep socio-economic gradients.

  108. It does not explain why it has got so much worse in the last 20 years. I accept that smoking is one factor, but that is only a small part of this argument. What else is going on?
  (Sir Donald Acheson) I am not sure we know. My colleagues may know better than I.
  (Sir Michael Marmot) The important thing to point out, although the headline figure of a 9.3 or 9.5 years' difference in life expectancy between the top and the bottom is very eye catching, if you think that abolishing heart disease completely, statistically, would add four or five years to life expectancy, then a nine year gap in life expectancy is like doubling the major cause of death; it is huge. That is very eye catching but what is underlying those figures as well is the fact that it is a social gradient, that each class has higher mortality than the one above it. Although it is tempting to think in terms of absolute deprivation, poverty, in fact that is an incomplete explanation of what is going on. Absolute deprivation is of course important and is bad for health, but things in general have got better. Most people's incomes have improved over the last 25 or 30 years but what has happened is that they have improved at different rates. So what we are seeing, if where you are in society matters to your health—and I can expand on that in a moment if you wish and I think it does—is increased inequalities over the period from the mid-1970s to the mid-1990s where we have figures. There have been big increases in inequalities. Whether there is a link between those increases in social and economic inequalities and what we have seen in mortality is an open question. I do not know how strong the link is. Certainly my own view of the evidence is that there is a link, but it is hard to say that the link has been proved. I do think there is a link. What we have seen is not that things have got worse in mortality terms for people at the bottom, but things have improved for people at the top and they have improved much faster, depending on where you were in the hierarchy. In trying to approach your question, one has to frame it that we are not asking why things have got worse in health terms for people at the bottom, because they have not, we should be asking why things have improved so much more rapidly for people at the top and more rapidly for people in the middle and less rapidly for people at the bottom. Why has the gradient increased, the social gradient. My own response to it is that I would take three approaches. The first is to ask, as we did in the independent inquiry, what the effect is of early childhood. Are we seeing something playing out which is the late effect? Whether it was the in utero environment, or what happened to children, is this the late effect of those early childhood experiences? The second approach I would take is to ask what has happened to risky behaviours like smoking, like diet, like exercise and that is very important but what that leaves out, and it is summed up in my third approach, is why these risky behaviours show a social gradient. I would suggest there is not a person in Britain who fails to understand the health consequences of smoking, so the social gradient in smoking is not the result of ignorance. Social gradient in smoking is the result of something else and it is that something else which is intimately related to where people are in the social gradient. That may affect smoking, it may affect diet, it may affect exercise but it also may affect the degree of security people feel, how much hope people have for the future, whether they feel that life is working in their favour or against them. This may sound airy-fairy, but we have evidence that those things are important for health and they follow a social gradient.

  109. I have certainly seen evidence about the importance of control and that sort of thing. I do not know if those are still current theories but there is some evidence from the 1970s and 1980s. Do you still think that plays a part?
  (Sir Michael Marmot) From our own study, we have been studying civil servants for the better part of three decades, the Whitehall studies, and in the first Whitehall study we showed this social gradient very clearly. For people who are not poor in any usual sense of the word where you are in the hierarchy was intimately related to mortality and coronary heart disease, from cancers related to smoking, cancers not related to smoking, accidents and other causes of death and so to all causes. In the second Whitehall study we actually inquired more into causes and we showed that people who had low control over their work environment had higher risk of coronary heart disease than people who had high control over their work environment. We have now been looking at the issue of how much control people have outside work and we have shown, particularly for low status women, women who tell us that they have no control at home, that they have a dramatically increased risk of depression subsequently. You talk, as I am sure you do, to your fellow GPs and none is in any doubt that that is important. People who feel that they do not control life circumstances are at risk of mental illness, depression, but they are also at risk of physical illness.

  110. One of the striking things we picked up from reading your report is that some of it is isolated studies, some of it is out of date data, which you commented on yourself. Do you think that appropriate new data are now coming on stream? Do you think that the Health Development Agency really will be able to establish evidence-based research to try to help us with some developments in the future?
  (Sir Donald Acheson) There is certainly need for more research in this field. The report which was published in November 1998 had all the evidence we could find; 529 references. Nothing was actually used that was not in the peer reviewed scientific press, so far as I remember. So the evidence was the best we could get. Things have moved on a wee bit in the last two years, but it is still a scholarly document which reviewed all the scientific evidence we could find in the English language at any rate.

  111. I am not at all criticising your scholarly report; it is an excellent report. You yourself commented that some of the data was out of date. Is more good data coming on stream and in the future can we look forward to the better quality data than you were able to use?
  (Sir Donald Acheson) I am not aware of a great deal being published since November 1998 which would have changed our conclusions, in fact I am not aware of anything being published which would change our conclusions. Yes, indeed, there is a need for more research in this field.

  112. Do you think therefore that the Health Development Agency would be able to enable such research data to come in or do you think we need to do yet more?
  (Sir Donald Acheson) The field must be open to people working in the Departments of Epidemiology and Public Health throughout the country. The Agency will do its best but it cannot do much on its own.

  113. What do you think are the most important drivers of health inequality in any community? What do you think is driving these inequalities which we are so obviously seeing?
  (Sir Donald Acheson) It has to be the socio-economic gradient. Of course Professor Marmot was referring to the Whitehall studies and I am one of those people who has actually worked in Whitehall. The thing about Whitehall and there are others here who worked in Whitehall, is that it is intensely hierarchical. It is like being in the armed forces. I have not worked in industry but where you are in this hierarchy gets to you. Fortunately I was at the top, but I have to tell you that with the difference in position and power between the Permanent Secretary and the people who push the paper around I am not surprised there is this steep gradient. None of them is in poverty, they all have pensions, the chance of ever being out of work or destitute is remote and yet you have something like a two or three-fold difference in mortality between the Permanent Secretary and the people who push the paper around and clean the offices. If anything would persuade you that there is a key area which has to be further researched about where you are in the pecking order, that is it.

Mr Hesford

  114. May I come back to the 20-year period we were just discussing and almost a bit of confusion as to why the figures you quoted earlier on, the five to nine difference, have got worse? The 20-year period largely coincided with a period of Conservative Government. If you want to give evidence, Mr Burns . . . For the record, Mr Burns was a Health Minister. In that period two things struck me as being either helpful or unhelpful as you might now tell me. One is that in your field you were not allowed to use the term "inequalities". That caused great distress to many working in the public health field. They could not give expression to what the evidence was saying. That was linked, you may say, to the Reagan economics of trickle-down, the idea that increasing wealth would cascade down to lower socio-economic people and that failed. Were the two things linked: the fact that that theory failed and it was known to fail, but those people working in your field were not able to give expression to that, for example, you were not able to use the word "inequalities"?
  (Sir Donald Acheson) If I may put my politics on the table, I have worked with both administrations, three different administrations, the present one and the two previous ones. I regard myself as totally non-political in party terms. The issue of variations or inequalities was just a wee bit silly. I do not think it was more than that. It did not actually stop the people who did the report called Variations in Health from looking at it in an objective way. It was not an important issue. With regard to economics and financial policy, I am not really qualified to speak except that we in our report here were clear that a redistribution of wealth was highly desirable as a means of reducing inequalities of health and it looks to me, but I am not an expert in this field, that the last two budgets have made such a redistribution in very real terms. I cannot measure it; no doubt you will get advice from economists, but there has been a substantial change.

Chairman.

  115. Has it gone far enough? What you are arguing is pretty radical.
  (Sir Donald Acheson) I think there is some more coming from what I hear in the newspapers.

  116. What you are talking about is a huge increase in the class differences in relation to health outcomes. What you are describing to us is very worrying. Would you say, looking at what is happening currently, that the Government are going far enough to address these huge inequalities which have occurred for whatever reason over the last 20 years?
  (Sir Donald Acheson) Speaking personally I should like to see some more redistribution of wealth.

  117. In what way? How do you do it? You are pushing at an open door.
  (Sir Donald Acheson) I think the Chancellor should go on doing what he has been doing. There is another issue which is a very interesting one. For example we found that pensioners found it very difficult to take up their benefits. Less than half of them took up their benefits and they certainly need them. I understand there is to be a campaign to help them to take up their benefits without feeling shame. There is something which we should be very glad to see, those of us who were concerned with the report, and we are also all of us glad to see that what used to be called the minimum guaranteed income is now linked not to cost of living but to increases in wages, which is one of our recommendations which we are very glad to see.

  118. You have just referred to pensioners and one of the big debates in this place has been on the whole concept of universal benefits versus selective means tested benefits and you just argued now that we need to increase takeup. There are some of us who favour a universal benefit system whereby you recoup through your taxation system. Rather old-fashioned thinking nowadays but it certainly seems to make sense in health terms from what you have said. Has that been an area you have looked at in your report, the whole issue of the structure of the benefit system impacting upon health outcomes?
  (Professor Whitehead) We did not look in detail at the structure of the benefit system.

  119. Not the structure but the actual principles underpinning it.
  (Professor Whitehead) What we did look at was the adequacy of the benefits to sustain a healthy diet and social participation, this sort of thing, which we thought was very important to health. What was clear from the evidence was that the benefits were not adequate, particularly for families with children. We were very worried about the inadequacy of the benefits for families with children. That was one of the recommendations, that really the whole system needed to be looked at to make sure that those benefits were adequate and the same with pensions. Universal versus targeted. The issue is that with a universal system everyone gets what they are entitled to, whereas with the targeted benefits where people have to claim, there are many people who do not claim what they are entitled to, so there is that balance.
  (Sir Michael Marmot) I do not want to get into the administrative details of how you organise your pension system because it is beyond me. If one takes seriously the issue of the gradient, the thing that bothers me with programmes which are simply targeted is that if you target at the very bottom, you miss the people who are in the bottom 20 per cent or the bottom 30 per cent or the bottom 40 per cent who are all at increased risk. If you take something like Sure Start, which I think is wonderful and I applaud the fact that it is going on—it is wonderful—however, it is aimed at the bottom five per cent. I am concerned with the children of the people who are in the bottom quartile or below the median because all the evidence suggests that literacy, educational performance, follows a gradient as does health. If there is a link between how well people do in the school system and health, and it follows a gradient, then simply targeting at the very bottom misses where most of the problem is. Most of the problem is not in the most deprived. If we actually argue, as we did, that we see no biological reason why everyone should not enjoy the same health as those at the top, then most of the problem is in people who are just below the median. It is not in those who are most deprived. By targeting at the bottom, you miss that. That is one point. The second is that I certainly do not want to enter the political argument as to whose fault it was but what I would say is that an approach which says smoking is bad for you, do not smoke, has clearly not worked for large sections of society. A failure to appreciate that people's behaviour happens in a social context means, in simple straight empirical terms that a strategy which is based on simply conveying information without taking into account people's circumstances will not work. You might say it is not the business of Government to ensure that a strategy to reduce smoking will work. The business of Government is simply to convey information. That is not up to me to make those sorts of decisions. What I can say is if you feel that the smoking rates in society are too high, simply conveying information will not work.


 
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