Examination of witnesses (Questions 120
- 139)
THURSDAY 16 NOVEMBER 2000
SIR DONALD
ACHESON, SIR
MICHAEL MARMOT
and PROFESSOR MARGARET
WHITEHEAD
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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