In the coffee room at my GP surgery is a bookcase. Like most furniture of its type it is little used these days because relevant links and resources are only a click away. A few weeks ago I pulled from it a copy of Sir Douglas Black’s groundbreaking 1980 report on inequalities in health, with the strapline: ‘the most important single document on health since the war’ (Labour Weekly).1
This heavily referenced work by one of the UK’s top scientists made recommendations to improve the health of the nation. An initial anti-poverty strategy was identified because this was the central issue recognised as being at the core of ill health. The key recommendations were for:
an immediate increase in child benefit;
larger child benefits to be progressively introduced for older children;
an increase in the maternity grant; and
the introduction of an income care allowance.
Further recommendations included:
the provision of free school meals;
improved housing;
a child accident prevention programme;
a comprehensive disablement allowance; and
better conditions at work.
The report stressed the importance of recognising the need for coordination between different arms of government, including an interdepartmental group with responsibility for health policy (note the emphasis on integrated working that is only now taking root). A Health Development Council with responsibility for tackling health inequalities was also suggested.
The authors acknowledged these recommendations would come at considerable cost, and in the early 1980s money was tight.
A more recent publication by Michael Marmot2 made similar recommendations 30 years later and there have been others in between such as the Acheson report,3 none of them fully embraced by government.
HOW THINGS COULD HAVE BEEN
At a time when all sectors of the NHS are under extreme pressure it is interesting to wonder what the system would look like now if the government of the day had fully implemented Black’s recommendations then, or at any stage over the past four decades.
The single biggest driver of poor health and social problems is income inequality.4 The Black report specifically set out to address this so it is reasonable to infer there might now be less illness, a healthier society, fewer hospitals on black alert, and overall a more manageable workload — with all the invisible savings that would be realised. How much more comfortable ministers would be now.
CHILD POVERTY
Child poverty is surely a predictor of continuing high demand on any future health and social care system, and will persist as long as nobody in office has the foresight to put long-term measures like those recommended by Sir Douglas Black into practice.
High-tech solutions and reorganisations of the service have their place but, when we have the capability to improve health on an epidemiological scale with some simple interventions, why don’t we concentrate on these first?
FINAL COMMENTS
When the Black report was submitted in 1980, instead of being properly printed and published via the normal channels it was arranged for just 260 copies of the typescript to be made available on the week of that year’s August Bank Holiday.1
The future of the NHS hinges on whether the government and its complex reorganisations can ever grasp this perennial nettle, so clearly defined by Sir Douglas Black.
- © British Journal of General Practice 2019