Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 120 - 139)



  120. I understand you have some information on the way income has redistributed since the current Government has been in power.
  (Sir Michael Marmot) Yes.

  121. Would you therefore concur with Sir Donald's assertion that recent budgets have certainly moved in the direction required to address some of these inequalities, from the information you have?
  (Sir Michael Marmot) Yes, I would. The Institute for Fiscal Studies has done an interesting study on the first four budgets. This is not looking at total income inequalities because globalisation, all sorts of things, affect income inequalities which are way out of control of Government, but looking at the effect of the fiscal system on income and inequalities and it shows very clear redistribution by decile. It is not taking from the top and giving to the bottom, it is by decile. The lower you were in the income distribution the more the fiscal regime has benefited you. It is a stepwise function. It is clear redistribution but not simply aimed at the very bottom, it is aimed step by step along the way and the people who have benefited most are at the bottom, the people who have benefited second most are in the second bottom decile and the third most are in the third decile. It is a very linear function. The analysis that the Institute for Fiscal Studies did last week after the pre-budget review on pensions shows exactly the same phenomenon. The predicted effect between 2001 and 2003 of the new pension arrangements will actually be to affect the gradient not simply the pension incomes of those at the very bottom.
  (Sir Donald Acheson) It seems as though somebody in the Treasury has accepted the socio-economic gradient of ill health and the model because what has happened in the fiscal policy seems to be matched exactly to that. I wanted to say something about smoking which underlines a point you made and that is that if you look at the prevalence of smoking since 1960 by social class, it has come down in both genders amongst professional people to ten per cent. It has been a wonderful result. But unfortunately if you look at the poorest off women, if you look at the poorest off women, it has not come down at all. In the poorest off men it has come down a bit. What has happened is that on average we have done marvels with our anti-smoking policy over the last 40 years, but unfortunately we have built in the differential of mortality due to smoking in a way which is one of the underlying causes of increasing inequalities and health. That shows that just putting up posters and doing all the things we thought were so good, is not enough. One approach to reduce the prevalence of smoking, which is suggest further increases in the cost of cigarettes. We were not prepared to suggest this because of the burden it would put on the poorer people. However but to make nicotine replacement therapy provided free of charge by a prescription on the NHS which you can get for as long as you need it, if your doctor is happy about it, seemed to us to be the way to help the least well off to stop smoking.

Mr Burns

  122. Why do you think it is that smoking has decreased so much in the upper levels but not in the lower levels, particularly given what has been over probably the last eight years or so from memory a significant deliberate increase in the price of cigarettes which would hit financially those people who one would imagine logically—and I know logic does not necessarily come into it—would try to give up because of the financial burden it was placing on them? Why do you think that just has not worked?
  (Sir Donald Acheson) We know that the degree of dependency, and addiction, to 20 cigarettes a day increases as you go down the social spectrum. The less well off have more difficulty in quitting. There are either higher nicotine levels in their blood, perhaps due to the way they smoke, but it may also be the way they feel about their life. The point illustrates Sir Michael view has been making that just to limit our efforts to the downstream "Stop Smoking" message and put the price up is not enough. We have to address the socio-economic background of tobacco addiction this and make it easier for the less well off, the more heavily dependent, to get off. That is where NRT comes in.

  123. Which, unless things have changed, is a more generous and more realistic approach by the Government to patches and some of the other things.
  (Sir Donald Acheson) Yes, there has been quite recently a more generous approach.

  124. What other role or initiative do you think Government should take to try to bring down the smoking levels more?
  (Sir Donald Acheson) I must say the recent improvement in the arrangement of the nicotine replacement therapy that a GP can prescribe it not just for a week, as previously, but as long as he things is necessary, is a tremendous advance. I think we will not get further progress unless we address the other socio-economic problems to which my colleagues have been referring. The one-shot approach to one downstream issue will take you so far but it will not take you to the root of the problem.
  (Sir Michael Marmot) May I come in? It relates to your question earlier about whether we need more research. Of course; I am an academic, we do research, of course we need more research. Take exactly this issue of smoking. Hilary Graham, who was on our committee, on the Acheson Inquiry, in her own research on smoking did very detailed time budgets of single mothers, of what they spent their time on and what they spent their money on. We know that nearly 100 per cent of these single mothers are smoking and what they spent their time and money on was on other people, on their children, boyfriends, whatever it was, on other people. The only thing they did for themselves was smoke. The only money they spent on themselves was for tobacco and the only time out in the week virtually that they had for themselves was when they had a cigarette. I would argue that people in those circumstances are discounting the future extremely heavily: in a sense they are saying "do not tell me about smoking and lung cancer in the future, I have enough problems right now. I do not care about the future consequences of smoking because I have problems just getting through the day and through the week". Do we need more research? Yes, we do need more research on people's hope and optimism for the future. We know that psycho-social factors affect smoking and that people's social circumstances affect smoking. If you then ask what you can do about it, my guess is we have to start in early childhood right from the beginning, whether it is intervention in utero, pregnant mothers, prevention of teenage pregnancy, all the way through childhood, the school system, so that people actually become adults with hope for the future, with the fact that they have an investment in the future. If not smoking actually helps that investment for the future then like most of us in this room, we make that investment because. We have an investment in the future so we do not smoke. If you have no investment in the future, it is a matter of no consequence whether you smoke or not.

  125. You have identified the problems with the financially less well off in society and poor housing conditions, poor education and everything. However great the task is, there is a way forward. You can identify it, improve the housing significantly, improve housing conditions, etcetera. Is there also a problem emerging then at the other end with stress related problems because of the pressures of work, the pressures of trying to maintain a standard of living or something, that maybe 40 years ago would not enter into a discussion like this at all? Presumably very little is being done to address that sort of issue at the moment and it is being left more up to the individual and the old cliche that you should relax and spend more time relaxing as well as working hard.
  (Sir Michael Marmot) This is music to my ears. I would agree completely with what you have just said. The Harris Poll picked up our Whitehall findings from the Whitehall Two study on the fact that every stress problem we identified followed a social gradient, that people down the bottom were having many more problems, and people in the middle were having more problems than those at the top. So he took our Whitehall Two questionnaire and added some other questions and did a poll of a US sample. I venture to suggest we would find exactly the same in Britain. Of something like 18 problems, all followed the social gradient except two. The two which were more common in the higher socio-economic group were having too much to do and looking after elderly relatives. The second one could be explained by the mortality rate that follows the social gradient, people down the bottom have fewer elderly relatives because they died, and the people of higher status were all complaining about having too much to do. That is the sort of thing everybody embraces. They like to complain, it is a macho mark and shows that you are successful if you have too much to do. Every other problem followed the social gradient. Problems with the work environment, problems with housing, problems at home, problems with children, every other problem followed this social gradient. I think you are absolutely right. Telling people to do yoga and relax is very worthy and will not do anybody any harm, but that is not the way to address the issue.

Mr Austin

  126. Basically on the psycho-social influences, I think you were saying that for example on addiction, tobacco or any other addiction, people who feel in control in their lives find it more easy to give up the addiction than people without control in their lives, and you referred to the feel-good factor, the being in control, as a determinant of health. I should like to go back to the retirement age and the pensions issue. It seems to me that for many people, when they finish their working lives at 60, or 65, there is not only this dramatic drop in their income, which clearly must have an impact, but on their sense of contribution and worth. Some of us find the idea of perhaps retiring at 60 an attractive proposition, provided the pension is there, but there are others who feel able to contribute and want to carry on working and increasingly in Government service people are being forced to retire at 60. Do you think there is a case for a flexible age of retirement for people who wish to continue working to do so? Have you done any studies as to the impact not just of the income but of people's sense of worth and wellbeing when they reach the end of their working lives?
  (Sir Michael Marmot) We have just embarked on such a study funded in part by the UK Government and the other part by the American Government, the National Institute of Health, an English longitudinal study of ageing, which amongst its questions will look at precisely this question. We have very little data to answer your question of what happens to people post-retirement in terms of their sense of control over circumstances and their feeling of worth or worthlessness. What we do know is that labour market participation in Britain is very low on an international comparative basis. By age 60 fewer than half of men are still in the labour market, still in the workforce. In France it is about the same as us. We look at Japan or the United States and it is more than 70 per cent by age 60. Your anecdotal evidence, I am sure, will be borne out by the facts that this is not something which is universally welcomed. Some people do not want to be out of the labour market by 60 and more than half are. They do not want to be out of the labour market. I asked an economist who did these studies whether there is any evidence that it is actually good for the economy to throw people out of the labour market by 60. Is it good or bad? He said "Too difficult a question. No idea". I am sure it cannot be good for everybody. Whether it is good for the economy or bad for the economy I do not know, but I am sure it is not for all individuals. For people who are in rotten jobs it may be quite good to have the relief from it but their economic circumstances will worsen. For people who feel they are playing a socially fulfilling part in society, to be removed without choice seems to me cannot be good.

  127. There is no retirement age for politicians. I am not sure about professors.
  (Professor Whitehead) In the report we did detail the socio-economic polarisation that goes on in older ages, the fact that increasingly we are getting some very affluent pensioners and some very poor pensioners and there is that divide which is increasing. There are pensioners with very low income, lacking the capacity and the opportunities for social evolvement, getting about, doing all the things you might want to do if you had free time. This polarisation at the end of life is a very worrying trend in itself. There is a gender bias in that as well; there is poverty among older women which is a particular problem as well.

Dr Brand

  128. May I just for the record say that I do not think the Chancellor has gone far enough in levelling off the socio-economic gradient? Given that we have accepted that link between the steepness of the gradient and health outcomes, where should the Government then be directing its interventions in the most cost effective way to improve health outcomes and health inequalities?
  (Sir Michael Marmot) There is no one answer. Our best judgement was that we had 39 areas which we thought the Government should pay attention to which formed the text of our 39 recommendations. Apart from highlighting three, we did not prioritise beyond those three. We did not for example say improve the lot of pensioners and forget children or improve the lot of children and forget pensioners. We thought that there ought to be action right across the areas in terms of Government policy. We certainly did not take the view, and all the research evidence would support this, that there is one single factor which explains the social gradient. It is a combination.

  129. The outcome of your report clearly is that it is not a pure health matter, it is a socio-economic matter.
  (Sir Michael Marmot) Absolutely.

  130. May I ask you on a matter of detail? Is it people's lifetime spent occupying a particular part of the socio-economic gradient or do they change their risk factors as they go up or down the scale? Particularly when we are talking about pensioners, where people can be in the middle bracket and then suddenly zonk down when they get older, does that have a significant effect on morbidity?
  (Sir Michael Marmot) It is a good question and the answer to your question is not clear. Whether what happens earlier in life, throughout life, has a cumulative effect or what happens now is important. Part of the answer comes from looking outside this country. When we looked at central and eastern Europe for example, the former Communist countries of Europe, what we saw there were absolutely dramatic shifts in life expectancy which happened very quickly. The gap between east and west opened up in the 1970s and 1980s so that what were then the Communist countries of eastern Europe lagged behind very badly, heart disease rates went up very quickly. Post-1989 there were dramatic shifts in the former Soviet Union. Health got dramatically worse after the fall of the old regime very, very quickly. This suggests that things that happen now can affect people today and tomorrow. It cannot just be what has happened to you in the past. Having said that, the evidence on the importance of the life course seems to differ for different diseases. For cardiovascular disease there seems to be a contribution which is important, both from early life and from current circumstances. If you classify people according to where they came from, their parents' social class, that seems to have an effect on coronary heart disease risk, independent of the class they end up in, but the class they end up in has an effect independent of the class they came from. Both seem to be important. For chronic bronchitis, it is probably the case that what happens earlier in life may be more important. If you grow up in a smoky environment with parents who smoke, with a lot of infection and you yourself become a smoker you have probably irreversibly damaged your lungs so that chronic bronchitis will be increased whatever happens to you subsequently. For other diseases, what happens currently is probably more important. The evidence for cancers suggests a minimum effect of early life: what happens in adult circumstances is much more important. That is why it is a slightly confusing picture, but it does suggest that dramatic changes, acute changes, can have acute effects, even though they are on a substrate of what happened to you earlier in life.

  131. It is very interesting when you say that it is not necessarily absolute poverty which determines people's risk but it is the spread. How should Government policy be influenced by that thought? One looks at the Waynes and Waynettas of the television, the sort of people who have no expectation other than to live the way they do. Are they going to benefit from a policy at the moment which raises everyone up slightly towards the mean?
  (Sir Donald Acheson) One of our recommendations which has not been mentioned is the first one and perhaps that to some extent deals with your point. The effect of some public health policies in previous times, which by accident have increased the health differential, was very much in our mind and we said this. Our first recommendation, which is one of the three areas we regard as crucial, is that all policies likely to have an impact on health, and that goes right across the board, should be evaluated in terms of their impact on health inequalities. This is to try to ensure that we do not do what we did with smoking, increase the differential. Further, health policies should be drafted in such a way that they favour the less well off; not the least well off. Any new policy in Whitehall, apart from Defence and Foreign Affairs, should be looked at in terms of what it is likely to do to inequalities in health. To address the issue of inequalities should favour the less well off. Secondly, a high priority should be given to the health of families with children. The third priority mentioned in our Report is that further steps should be taken to reduce income inequalities and improve the living standards of poor households which have been diverging in recent years.

Mr Hesford

  132. May I just ask a few questions about the latest Government initiatives to counter health inequalities, the National Plan for example? Do you have a view on the fact that the National Plan does want to look at national inequalities as a sensible way forward? Within that target, what type of targets might there be? What should they be? Is it easy to formulate such targets so that Government can actually get a grip or have a sense of where they are going, knowing that the effects of their targets and policies are actually beneficial and issues around timescale?
  (Sir Donald Acheson) My own view is that without targets, nothing much will happen. It is important to have targets to concentrate the mind and hopefully to enable one to measure progress. If it is a question of targets or no targets, I would strongly favour targets.
  (Sir Michael Marmot) I strongly supported having targets in the National Plan. I was involved in the discussions and I was strongly in favour of having targets for the same reason. What is important about having targets is to do the hard thinking as to whether we in society have handles on the right policy leaders. The exercise of trying to set a target is a very good discipline to ask what impact there would be from the range of policies which is currently in place, quite apart from what new policies might be put in place. What will the impact be on health inequalities? Of course the information base in terms of actual quantitative estimates is inadequate. We do not actually know what the quantitative effect will be of the whole range of policies we talked about, income, pensions, Sure Start, education, initiatives for communities and so on, a whole range of policies which in our judgement, as reflected in the Acheson Report, will reduce health inequalities but by how much we do not know. The discipline of going through the exercise of setting the target forces one then to try to ask these hard questions. The other part of your question was how we monitor how we are doing. We have mortality but that is a very sluggish indicator. We do not get the mortality regularly and it is downstream. It is a relatively sluggish indicator. What we obviously need is to monitor morbidity as well and that is far more difficult. We have the health survey for England, the health survey for Scotland, which gives some guide. One of the big problems is—you perhaps do not want to know this, but let me say it anyway—that even to manage the NHS, quite apart from monitoring inequalities, the necessity to be able to link medical records, to be able for example to look at hospital discharges as a measure of morbidity and link that to people's personal characteristics, this is difficult technically, but soluble. One hopes that the Office for National Statistics will solve the problem. It is still not easy. It is easy in Scotland. They have solved it in Scotland. We have not solved it in England and I hope it will be solved technically. One of the problems is that the data protection act is going to kill off research and monitoring. We are all in favour of ethical standards and we are all in favour of protecting people's privacy. But the way that is now going, it will kill off research and it will kill off performance management. It will actually stop you knowing what is going on in terms of morbidity. A perfectly good purpose, which is understanding the trends in the nation's health, is in danger of being killed off if the rather Draconian measures to protect, not to allow linkage of data records, in the interests of privacy, go through as they look like they will and you will have a far more difficult task of monitoring what is happening to health inequalities.
  (Professor Whitehead) May I make a comment on the targets and the national plan? I welcome the fact that we are going to have a national inequalities target and I have been pressing for that for a long time. There is a great advantage in having what I call symbolic targets, even if nationally we have a very general inequality target, which really emphasises the commitment and the direction we should be going in and the Government's commitment. That is very important.

  133. Is there an issue around symbolism and credibility if they are just symbolic?
  (Professor Whitehead) Yes. There are two types. There is the symbolic one, which I think serves a very important purpose and I would advocate. There is the operational targets which have to be specific and document the population, the timescale, the indicators, etc. They have their use as well. I would advocate that those are set in terms of the determinants of health rather than focusing on diseases and mortality or morbidity, but look at the determinants of health which we can influence. The Prime Minister's poverty target of reducing child poverty is an excellent health equity target. We could focus more on targets like that.

  134. What others in that area could there be?
  (Professor Whitehead) Others in that area, for example, in Sweden have said, are to do with reductions in income inequality, improvements in the psycho-social work environment, tangible things that you can have control over and work towards. Could I add to what Sir Michael said about monitoring, because I think in the rest of the NHS plan other than chapter 13, which is the inequalities chapter, there are many targets and performance indicators mentioned which are just averages? They are expressed in terms of averages and a lot could be done to specify within any of the targets to do with access, outcome of care, to look at the distribution of that outcome.

  135. Do you mean there is a statistical danger of looking at averages?
  (Professor Whitehead) If you just look at the average of how many people have access to a service, for example, you might miss the fact that there were whole groups of people, perhaps the less well off, who were not getting access to that service. In the same way, if you look at treatment, and you can see that there are improvements in outcome of certain treatments, but if you do not look at what is happening to different groups in society you might again miss that some groups are not having any benefit from the treatment while others are having great benefit. A requirement could be built into all the performance indicators and targets, set right across the board for the NHS, to look at the distribution of outcomes.

Mr Burns

  136. Sally McIntyre, who will be giving evidence shortly after you, describes the "tension between the goals of generating overall health gain and the reduction of inequalities", in other words some overall health gains actually exacerbate inequalities, while targeting the disadvantaged may produce less aggregate health gain at greater cost. What do all three of you think about that? Do you agree with that? I suspect maybe you would have some doubt in the light of what you have been saying earlier?
  (Professor Whitehead) I do not see a tension because one of the principles of promoting equity in health is that we level up, we do not level down. What we are trying to do in public health policy is to improve everyone's health and to improve the health of the worst off even more so. I actually do not see that tradeoff. I think we should be working for both.
  (Sir Donald Acheson) The example which I gave of what happened as a result of our well-intentioned policies to reduce the prevalence of smoking is precisely this, that after 30 or 40 years of effort, we ended up with a situation where although superficially it seemed a great success was in fact less successful that it seemed. On average prevalence had come down from 60 per cent to 30 per cent in men and 40 per cent to 20 per cent in women on average, but if you looked at what happened to the differential, it was a disaster, and in the extreme cases in least well off women the prevalence of smoking now is the same as it was in 1960, 45 per cent. It is the poorest women who are more likely to inhale and are probably more likely to be in close contact with their children when they are smoking. This is exactly why we consider that any policy which is likely to influence health should be looked at in terms of how it will affect different social classes and it should be drafted to take that into account.
  (Sir Michael Marmot) There may be a tension between a simple value for money approach and an approach which looks at distribution. Let me give you an example. I shall start with a fact and then make an assumption. The fact is that cancer survival varies by social economic position. We know that. For most cancers people of lower socio-economic position have worse survival; once they have got the cancer their five-year survival is worse. The assumption, which may not be true but let us assume for the moment, is that that somehow reflects worse disease that is less responsive to treatment in people of lower social position. If you took a simple value for money approach, you would say let us invest our treatment resources in people who are more likely to benefit. Given that people of lower social and economic position are less likely to benefit from cancer treatment, we will not treat them, we shall invest our limited resource in treating those where we get the biggest bang for the buck. That is people of higher status, if my assumption were correct that people of higher position are better able to respond to treatment. They will get greater benefit. We shall forget the rest and we shall treat the ones where we get the most value for money. Most of us would probably find that unacceptable. We can say no, we have to look at distribution. We cannot simply look at value for money. The evidence which came to us on the committee in education was exactly the same as the example I have just given for cancer. For a given quantum of education expenditure, middle class kids will get greater benefit in terms of improvement in learning than kids from disadvantaged backgrounds. If you took a simple value for money approach, say let us invest in the middle class kids. New computer skills, let us teach the pupils from favoured backgrounds, they are the ones who are going to grasp these new computer skills. Literacy, mathematics, invest in the middle class kids, forget the rest, because we get more value for money from investing in the middle class kids. I would argue that society as a whole suffers from doing that. We have a less educated, less well trained society and a less healthy society. If you took a narrow value for money approach and ignored the distributional effect of your policy, I would say we would all suffer.

Mr Austin

  137. The local health authorities have a responsibility to develop the health improvement programmes to improve health locally. At the same time a duty is being placed on local authorities to draw up their community plan for the social wellbeing of their areas. Do you think there is a case for combining these roles in some way? Sir Donald, you have said very clearly that you feel the place of the Director of Public Health is within a health context, but is there an argument for joint appointments and joint working in this?
  (Sir Donald Acheson) Yes, there must be an argument for better relationships and closer coordination. I feel that is right. One of the difficulties used to be, and it may not be the same now, that there are differences in boundaries which make it a problem. But is there are difficulties when you try to relate health authorities to local authorities. Leaving that aside, I would certainly support any measure which brought the coordination between the work of local health authorities and local authorities into a better state than it is. At the same time my view would be not to take the radical step to change the locus of the Director of Public Health to the local authority. It would gain little and it would be immensely wasteful in human resources and upset.

  138. May I ask a further question which relates to the relationship between the local authority and health? With the proposed abolition of community health councils the scrutiny role is being given to local authorities. Whereas that may address the criticism that there has been a democratic deficit within the Health Service, there is a suggestion that maybe this could bring collaboration and cooperation between the local authority and the health side into some doubt. Would you care to comment on that?
  (Sir Donald Acheson) I hope it will. I do not think the previous arrangement worked really and I think it was right to abolish those institutions but it must be replaced by something which is more effective.

  139. You do not think it has the seeds of conflict where one authority has a scrutiny role and the other in terms of collaborative work.
  (Sir Donald Acheson) It might be constructive.

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