Interview

A matter of social justice

The disarmingly radical inquiry into Inequalities in Health has recently been published by the government. Its distinguished chair, Sir Donald Acheson, spoke to Geof Rayner about reaction so far

There has been a lot of media coverage of your report. Has any of it surprised you – or alarmed you?

The press has been excellent. There were two bits that concerned me and made me feel that I needed to write a reply. In the Guardian there was a leader – the feature pieces were excellent – which suggested that we were being constrained by ministers. This was something I had to answer. The leader had got targets mixed up with policies. Our terms of reference did not include the setting of targets. The scientific advisory group was concerned that this meant that the redistribution of income should be 25 per cent or something by a given year. So I went back to Ministers - and this is in the report – and they said that we don’t think that this is for your scientists, which I agreed with. How much and how quickly these things should be done is a matter for government.

To clarify this point a little further, was this issue also bound up with the dispute with ministers on the setting of targets in the green paper on public health?

Exactly. They’re not sure about national targets. It cannot be accidental that the health strategy that I was involved in with the last Conservative Government had about 29 targets and within the last year the National Audit Office looked at what had happened. Of the targets set in 1990/91, most had not been met, and in one or two the trends had gone in the other direction. I suspect that this may have influenced Ministers. Fortunately, for the people who did that they’re no longer in office – as each one of those targets would have been like St Sebastian’s arrows – 29 of them. This is the result of an adversarial system. In Sweden or Netherlands targets are agreed by the people.

Do you accept the criticism of the Financial Times that you didn’t have an economist on the enquiry team?

I originally thought up a scientific advisory group of 10 people including an economist. Ministers asked if it was a bit large. Also I think they said that you should stick to scientists. The question is: are economists scientists? If we had an economist I reckon we would have taken another year. My view was that we shouldn’t limit our suggestions to things that you should cost. Look what they have done today [the announcement on new pension arrangements]. That’s wonderful. Whether they did it because of us, historians will analyse.

You must remember they had a draft of our report last July. I deliberately – in principle – had discussions on what we might do with each government department in the process. And we had a very strong bit about pensions, and how pensioners need more. I think we did the right thing, not to say spend another £2bn but ‘we recommend uprating of benefits and pensions according to principles which protect, and, where possible, improve the standard of living of those who depend on them, and which narrow the gap between their standard of living and average living standards.’ Well that’s exactly what they’ve done. The duty of scientists is to say: ‘We have gross inequalities in health in this country. Our society seems ready to be relegated from the premiere division.’

The recent Social Attitudes Survey suggests that people are becoming less concerned about inequalities in Britain. Is there a gap between what the government is able to achieve – based on your advice – and what they think they have to do to get elected?

This is fundamentally a matter of social justice. There are lots of governments that want to get elected and aren’t interested in social justice, but that’s up to them. All I can say is that I’m interested in social justice. When people say they want to get elected again and it’s the middle class who brought them in, my answer is that if they don’t do something about this it will haunt them in future, because they won’t be able to say what they said in the past, because they’ll be a different party. We are now bottom of the health league. This country I’ve been living in the last 70 years — who the hell have I been voting for?

It is interesting that we are next to the US, which is the worst. Is this due to the fact that over the last twenty years we have been trying to emulate the US?

What we’re saying is that that inequalities graph has to shifted from top to bottom. We’re not saying is that this is about social exclusion.

What Tony Blair and company are doing at the moment is something about a few thousand people. The thing which people have psychological denial about is that this is not a dichotomy between poor and rich, it’s a hierarchy – a gradient.

Is the policy on social exclusion a distraction from social justice?

It’s a cop out. It’s not fair. The worst-off do need the most urgent help. The answer to the question is that if they don’t do something about this, it will haunt them. If they don’t do what they promise in the Green Paper – the reduction in health inequalities – I will shame them. Or my ghost will. It’s promising what they’re doing. The tobacco stuff. The standardisation of benefits on a good level. One recommendation was that bus passes are brought up to the London level. They’re doing that. Good on ‘em.

You have said that you don’t want the government to pick and chose among your recommendations, but there’s no implementation process to your report. It’s now the end of your job.

Unless they deal with the policies on a broad front, the benefits will be quite small. There need to be both upstream and downstream measures. In the case of the former, if you increase the cash available to the huge number people without professional pensions, that will have enormous benefits – heat, clothing, exercise – whereas if you do something like nicotine replacement therapy on the NHS, a downstream measure, that will have a direct benefit. My view of what they have done is that it’s insufficient. They looked at our recommendation and decided it was too expensive. They will give one week’s free Nicorettes to people who are prepared to accept counselling – if they said one month’s, I would say that was a good start. You say that I have no formal role (in implementation), but after three months I will look and see what’s happened and then the next time I have the opportunity to speak in public I’ll say what’s happened and what hasn’t happened.

Which of the recommendations is the most important?

It’s in the synopsis, which I since would have liked to have rewritten. The first is: ‘Health impact assessment should now be replaced by health inequalities impact assessment’. Recommendation two should really be: ‘All policies should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce such inequalities’. That’s buried in there, and that is extremely radical. My view is that if they don’t do that, nothing much will happen.

I personally think that in the Cabinet Office there should be a unit which undertakes health inequalities impact assessment in relation to all social policy which is coming forward. There is a such a group in the Environment Department doing environmental impact assessment and there is one in the Department of Health doing health impact assessment, but improving health doesn’t necessarily reduce inequalities.

Independent Inquiry into Inequalities in Health Report. Chairman: Sir Donald Acheson. The Stationery Office, £19.50. The report is also available on the Internet (free): http://www.official-documents.co.uk/document/doh/ih/ih.htm.