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Fawww.fabians.org.ubk i an Rev iewSpring 2008

The quarterly magazine of the Volume 120 no 1 £4.95 REVIEW OF THE SPRING l a e T n a i r d A Gordon, hear the call for change The Prime Minister is ‘Best at his Brownest’ and should return to the strategy which won him the leadership last year

The Brown government risks being not defeat the call of ‘time for change’ corrective. Those in the Cabinet’s writ ten off before its first anniversary. next time. He was right. But will vot - Brownite centre who know why nar - The greatest frustration for Labour ers be able to point to even three key rowing the gap matters have shied supporters is just how winnable the points of ‘change’ if asked at the end away from getting out in front of the next election could still be were both of his first year as Prime Minister in Prime Minister – perhaps sometimes government and party to demonstrate June? still acting more as advisers than a strategy and appetite to win it. Frustration two: the party’s internal Ministers. They should realise that if Frustration one: there is no great debate is badly stuck. The left worries only a ‘No Turning Back’ is mystery about the Prime Minister’s that countering southern discomfort articulated, the call for ‘change’ will core vision, though voters could be would cost Labour’s soul. The Blairite be lost by default. forgiven for not knowing that. The ar - right flank worries about appeasing Frustration three: why is Labour’s gument that links policy together – Guardian-reading liberals. Labour instinct still to cautiously hoard politi - that Britain should compete on high won’t recover by debating which vot - cal capital? What for? Caution was value skills, not low wages, by un - ers it doesn’t want. partly a successful New Labour strat - locking the talent of all to ‘race to the There is no real chance of any lead - egy of quiet advance, partly too, a top’ in the global economy – is true, ership challenge, nor should there be. neurotic under-confidence which but too technocratic. This must be Those who lacked the support to put could not recognise when arguments translated into a public political argu - up a candidate when there was a va - were being won. ment about what Labour wants to cancy last year should shut up when it Eleven years in, the calculus of risk change about Britain, around which a comes to stoking media speculation must change. Whether the Labour winning electoral coalition can be re - about something which is not going to Government has two or seven years built. That should involve mobilising happen. left in office, its central mission must progressive support for the cause of But we need a more outward-look - be to embed and Tory-proof a progres - ending child poverty while showing ing and open debate about Labour’s sive Labour legacy against future po - how the argument that every child de - core mission. Few – if any – of John litical change. serves a decent start and the chance to Hutton’s Cabinet colleagues agreed That means ditching tactical trian - fulfill their potential can resonate with the content and tone with gulation, still too often the default across Middle too. which he celebrated ‘huge salaries’ mode of this Government. Cleaving The challenge is not just one of and people who ‘climb without lim - the tactics of 1997 to the politics of communication but political strategy its’ at the top. Yet only Hazel Blears, 2008 suggests a failure to understand too. Gordon Brown recognised last concerned about ‘social apartheid’ New Labour’s success in converting spring that ‘more of the same’ could between rich and poor, offered any the Conservatives to cont’d

Fabian Review Spring 2008 1 THE REVIEW Email your views to: [email protected] progressive aspirations and language. on the incumbents, not a choice be - Mark Penn in Washington. Then make It amounts to an offer to fight the gen - tween alternative governments. a fairer Britain the defining mission: eral election on David Cameron’s Labour must offer that clear choice. take risks for the cause of child poverty; terms. The Conservative leader wants So what needs to change? Get the make clear what climate change de - voters to think there is little difference Downing Street machine in place, but mands of us all; go for electoral reform between the parties. That election cancel Number 10’s subscription to PR and a written constitution. If not now, would simply become a referendum Week . Leave Hillary Clinton’s pollster when?

ways which make members of other beginning of our New Year Conference groups feel alienated, insecure or un - – the biggest UK public conference on safe." You can read Hazel Blears’ full global politics. Over 700 people de - speech at http://fabians.org.uk/events bated with 50 leading speakers – on is - Gordon Brown /speeches/blears-housing-speech. sues including how George Bush’s told the Fabians departure could lead to change in he wanted an global politics, what the rise of Asia Iraq inquiry means, Britain’s role in Europe and the after all lessons of Iraq. We finished the day with the other Miliband – Ed – seeking In the last Fabian Review , the Foreign delegates’ ideas for the next Labour Secretary told Tom Hampson that he re - party manifesto which included a pro - jected our call for a full public inquiry Inheritance tax posal for a ‘poppies for medicine’ cam - into the Iraq war. This gained consider - was in need of paign to licence poppy production in able media coverage and Fabian some friends Afghanistan, to deal with a worldwide General Secretary Sunder Katwala morphine shortage and improve local wrote to the Prime Minister, arguing Over recent weeks the Fabians have livelihoods. You can read full write ups that Labour’s ability to reach out and been building a coalition and campaign of the conference at http://fabians.org. work with those outside party politics to make the case for inheritance tax. uk/events /events-news/newyearcon “will depend on acknowledging and Alongside our Fabian pamphlet, How to ference-08. learning the lessons of Iraq”. Gordon Defend Inheritance Tax (supported by the Brown replied in a lengthy letter that TUC and which Fabian members will there would be a full inquiry after all: receive in their mailing with this issue “There is a need to learn all possible les - of the Fabian Review) we also ran a de - sons from the military action in Iraq and bate at the House of Commons with its aftermath." Brendan Barber, General Secretary of the TUC, Martin Narey, Director of Ben Bradshaw Barnardos, and pamphlet author Stuart wanted to make White. On 15 April the Fabians sent a health more letter to the Guardian , signed by MPs, equal Hazel Blears trade unionists, policy makers, academ - said it is bad ics and writers, defending the principle The Fabians held a major series of five for communities of inheritance tax against political at - seminars on narrowing health inequal - when one tacks. We will continue to work with ities between November 2007 and ethnicity other organisations on fair taxation. You March 2008, including sessions led by dominates can read the letter on our website at health ministers Dawn Primarolo, Ben http://fabians.org.uk/publications/pu Bradshaw and Ivan Lewis, and emi - At the beginning of April the Secretary blications-news. nent academics Julian Le Grand and of State for Communities and Local Sir Michael Marmot. The Fabian Government told the Fabians that no Health Inequalities Forum seminars one faith or ethnic group should domi - continued the work of the Fabian nate a town or city to the exclusion of all Commission on Life Chances and others. Launching the Fabian Housing Child Poverty, explored the major bar - and Community Policy Network, riers to narrowing inequalities across a Hazel Blears said that "There is nothing Fabians change range of key health policy areas, and wrong with enclaves of particular the world sought to suggest directions for the fu - groups – every city benefits from its one step at a ture strategy on health inequality that China Towns, Little Italies, or as in time we need. The Forum was kindly sup - , Bangla Town, Kangaroo ported by Sanofi Aventis and you can Valley, or Little Korea." However, she Foreign Secretary David Miliband pre - read full reports on all five seminars at argued that “No neighbourhood dicted that a ‘civilian surge’ would re - http://fabians.org.uk/events/events should be dominated by one group in shape global politics. He spoke at the /health-inequalities-forum.

2 Fabian Review Spring 2008 FABIAN REVIEW Life expectancy is up but the gap remains See Sir Michael Marmot p19

Fabian Review is the quarterly journal of the Fabian Society [email protected]

Editor Tom Hampson Books Editor Hannah Jameson

Fabian Review , like all publications of the Fabian Society, represents QUESTIONS WE’RE ASKING Cover story not the collective view of the Society, but only the views of the Live longer under Labour 4 individual writers. The Hannah Jameson responsibility of the Society is limited to approving its publications as worthy of consideration within The Fabian Interview the Labour movement. Dawn Primarolo 7 Printed by The Colourhouse Interview by Tom Hampson London SE14 6EB

Designed by SoapBox How Labour can win 10 with the NHS ISSN 1356 1812 Dr Neil Goulbourne Live longer Win with the NHS Fabian Society What do people think Can championing a 11 Dartmouth Street of the NHS, and how preventive NHS offer A shot in the arm for 12 London SW1H 9BN Telephone should it change? an electoral boost? health equality 020 7227 4900 Mary Creagh MP Fax Cover story, p4 Neil Goulbourne p10 020 7976 7153 [email protected] 8 policies for a 14 www.fabians.org.uk healthier nation , Bryan Jones, Dr Howard Stoate, Chuka Umunna, Sunder Katwala, Tim Horton, Dr Philip James, Tom Hampson and Louise Bamfield

General Secretary The Fabian Essay Sunder Katwala Reducing inequalities in 19 Research Director Tim Horton health: a policy choice MM Arrrgh! Feeling better Editorial Director Michael Marmot Tom Hampson Should school places Which policies would Events Director be dependent on make a big difference Jemima Olchawski having the MMR jab? to the nation’s health Books Research Fellow 58 countries falling apart 24 Louise Bamfield David Mepham Research Fellow Mary Creagh, p12 8 policies, p14 James Gregory Head of Communications War and peace 26 Rachael Jolley Hampstead Usama Hasan Editorial and Town Frognal Marketing Manager and Fitzjohns Hannah Jameson ortune Green Stress balls 27 Events Manager West Stewart Lansley Tim Gore Hampstead Events Manager Belsize Rosie Clayton Swiss Cottage When the personal 28 Events Manager Kilburn Fatima Hassan becomes political Events Assistant Ed Wallis Big differences Falling apart Finance Officer How can we reduce How can we help the The Fabian Society Margaret McGillen health inequalities bottom billion? Local Societies Officer Noticeboard 29 Deborah Stoate Membership Officer Fabian Bookshelf 30 Giles Wright Essay, p19 Books, p26 Listings 32

Fabian Review Spring 2008 3 As the NHS hits 60, we ask the big questions:

 What should the NHS do next?  How can the health service tell its story of supporting parents?  Is there the public appetite for a local, more preventive NHS?

As Hannah Jameson shows here, our YouGov poll suggests that people love the NHS for all its flaws, that there is a real appetite for a health service that prevents illness rather than treats it and that after 11 years of Labour government, people may not want nanny, but they do want a state that provides them with good support and information.

4 Fabian Review Spring 2008 1. A preventive health service. The New Labour story on health has been thoroughly ab - sorbed by the public. But Labour has become a victim of its We’re for it – but we’re not quite own success. When asked what funding priorities should be in the future, 66 per cent said they wanted more hospital doc - sure what it is. tors and nurses. When asked whether any new money for The public recognise that we need a wellness rather than a nursing should be spent on nurses for schools or in hospitals, sickness service – an NHS that is able to put into practice 86 per cent said hospitals. This suggests the means have the old adage that ‘prevention is better than cure’. 52 per begun to obscure the ends. cent of respondents to our survey agreed that the NHS The challenge for government revealed by this survey is should concentrate more on preventing disease and pro - clear. In order to improve public health we need a preventa - tecting good health. But how successful have government tive health service. But building on the public’s tentative and the health service been at translating positive re - recognition of this will mean presenting a vision of what that sponses to preventative health into realistic expectations? service will look like that is more appealing than the district Honest politicians acknowledge that taking preventative general hospital version that currently occupies the public health seriously is unlikely to mean local health care provi - imagination. It will mean taking on the assumption that sion stays concentrated in hospitals. But in the cut and thrust schools or high street clinics are less part of the health service of electoral politics it has been all too easy for Labour to point than hospitals, and finding ways to channel the enthusiasm to the huge programme to build new hospitals, the 85,000 for hospitals towards primary care instead – towards GPs new nurses, the 32,000 additional doctors as if the hospital and polyclinics. There are promising signs for preventative was at the heart of our vision for the new NHS. health; people are for it, but government ministers and Labour MPs must be brave and explain what it is, rather than hiding behind their district general hospital. The National Health Service focuses on both prevent - ing and treating illness. Looking to the future do you think the balance is right? Which of the following is 2. I h the NHS closest to your view? NHS spending in 2007/8 was triple the level in 1997, yet The NHS should concentrate more on preventing 52 our survey shows that there is still considerable support disease and protecting good health. for further spending – especially on the left. 51 per cent of The NHS has the right balance between treatment 31 Labour identifying respondents said government should and prevention/protection. continue to increase levels of funding, and increase taxes The NHS should focus more on treatment and 9 less on prevention/protection. if necessary to pay for it. The naked argument Labour made in their first term for increasing taxation to fund the Don’t know. 8 NHS still resonates today.

There will always be some limit to the money that the NHS can spend. Which two or three of these do you Which of these statements comes closest to your view think should be the NHS’s greatest priorities? regarding the funding of the NHS?

More hosital doctors and nurses? 66 Total Lab% Con% LD% Finding new ways to deliver healthcare locally 41 The government should continue 38 51 21 43 More GPs 31 to increase the levels of funding, Specialist cancer care 29 and increase taxes if necessary Better access to free fitness programmes 26 to pay for it. Paying for expensive new drug treatments 23 The NHS receives enough money 50 40 67 42 and should use it better Building new hospital buildings 12 The NHS could provide a 4273 Campaigns to reduce obesity 12 reasonable service with less money, Greater privacy in hospital 11 so it should receive less and taxes Support for local pharmacies 8 should be cut None of these 1 Don’t know 87513 Don’t know 4

But what is more remarkable is the support for current lev - If there were a limited amount of new money for extra els of funding amongst Conservative identifying respon - nurses and a choice had to be made would you prefer dents. Only 7 per cent agreed that the NHS should receive to see more new nurses in schools or more new nurses less funding and that taxes should be cut. It shows the extent in hospitals? to which the small state conservatives, who have tradition -

More new nurses in schools 10 ally argued for less public service provision and conse - More new nurses in hospitals 86 quently lower levels of taxation, have been isolated in mainstream debate. Don’t know 4 Arguments for private provision of healthcare – until re - cently made by the Conservatives – also seem to have lost

Fabian Review Spring 2008 5 POLLING ground. Not only are Conservative identifiers committed to governments have a legitimate role in improving the public’s public funding of the NHS, but the majority agree that it is health. 51 per cent of all 18-34 year olds agreed that it is the commitment of the NHS to free treatment for everyone rightly the government’s role to try to reduce levels of obesity that means it is one of our great national symbols. and ensure people make health choices, 15 per cent more than respondents in the over 55 category.

The NHS is sixty years old this year. Which of the fol - lowing best describes your attitude to it? Which of these statements comes closer to your view? 18-34% 35-54% 55+% Total Lab% Con% LD% Given the importance of diet and 51 41 36 Whatever problems the NHS may 70 80 56 79 lifestyle on your health, it is rightly have, its commitment to free the government’s role to try to reduce treatment for everyone means it is levels of obesity and ensure people still one of our great national symbols make healthy choices The NHS was a good idea for its 25 15 39 13 We already have too much of a 43 56 62 time but we now need a different nanny state - people should make way of running modern healthcare choices about their own lives and provision their health without interference The NHS was a bad idea from 1133 Don’t know 632 the start; it should be abolished and replaced with something completely different Don’t know 3425 Overall, our survey showed that people wanted govern - ment interventions to help them to improve their health, whether that was providing free entry to swimming pools But is there a downside to this broad base of support? The and leisure centres or introducing traffic light labelling on NHS turns 60 this year and, as our survey shows, has estab - food. They consistently want more information, advice and lished itself as a national institution. Is there a risk that affec - support – an enabling state that makes it easier for them to tion for the NHS will limit its ability to evolve to meet 21st make the right choices. But younger people were more likely century health challenges, fixing it as a nostalgic tribute to a to accept an even greater role for government than older re - bygone era? The NHS was a radical initiative 60 years ago, spondents, for example by limiting the amount of salt in food and its advocates had to struggle hard to argue that its model by law and adding fluoride to the national water supply. of general hospitals and GPs’ surgeries was the best way to According to the Wanless review, a sustainable NHS that improve the nation’s health. This survey suggests that a sim - maximises life expectancy and health status will require citi - ilar battle may need to be fought today to win the case for a zens to be fully engaged in maintaining their own health. Our new model of the NHS fit for the task of improving the na - survey suggests that individuals and families accept respon - tion’s health again. sibility for their own health, and that increasingly they recog - nise that government has a clear role to play in providing good information, making healthy choices easier, and setting the framework within which we make decisions about our 3. From the nanny state to the health. They don’t need a nanny, but they do need sensible parents’ supporter government support. Fear of being labelled the ‘nanny state’ has long dominated This poll was made possible by the gener - British politics. But our survey suggests that many people are ous support of the Royal Pharmaceutical comfortable with high levels of government intervention. Society of Great Britain. You can read the Younger people in particular are more prepared to accept that full poll online at www.fabians.org.uk

MANIFESTO HEALTH POLICIES Make swimming pools and leisure centres free

One of Labour’s most popular polices in 1997 was making admission to our great museums free. Visitor numbers increased and voters saw it for what it was – a measure from a government confident in its support for education and culture. In 2008 we should do the same for swimming pools and leisure centres. Swimming is free in Oxford, and Bristol if you’re under 16 and Ken Livingstone has supported London Boroughs who have experimented with free access. But why only young people and why not nationwide? This was by far the most popular policy with our poll respondents and allowing free entry would clearly show that this government understands the new role it should be taking on health – supportive, preventive and egalitarian. HJ

6 Fabian Review Spring 2008 THE FABIAN INTERVIEW

Tom Hampson meets with a What story frustrated minister and tests out some CAN Labour election slogans tell about health?

If you were Dawn Primarolo, what would you do? How would you describe what this government is up to on health? In this doggedly persistent administration in search of a narrative, with its strong record of improvements in public health and investment but with – as Sir Michael Marmot shows on p17 – still shocking lev - els of inequalities in health outcomes, would you be able to describe your vision of the future of health policy? There’s an election manifesto to write, so let’s try out some possibilities. First up is ‘The parents’ friend’ . The government has recognised for some time that if it gets this right, it could be one of its strongest cards with the electorate. During Labour’s time in power there has been a big change in the way health serv - ices work, and they are much more re - sponsive to the patient as ‘consumer’ than they used to be. But we are still lacking the sense that the state is ‘on your side’ if, say, you’re liv - ing in damp housing conditions which are affecting your health or when you’re shopping at the su - permarket, choosing your enter - tainment, using public services or seeking information and sup - port (as our poll shows people want). Supporting parents needn’t just be about better in - formation about, say, healthy eating, it can also be about sup - port against pester power, against large corporations seek - ing to exploit your children, and against pollution. As Primarolo says, “Public health has moved from being about

Fabian Review Spring 2008 7 THE FABIAN INTERVIEW the great crusades for clean water and decent living across public health is that real change is so slow – conditions to today when the greatest threats to our amongst food manufacturers, supermarkets, employers health and wellbeing are the products of our modern as well as with individual members of the public. In living.” Boris Johnson’s campaign he called some of But making the link between these quality of life ar - Livingstone’s more coercive measures ‘cattle prod poli - guments and a political argument is not easy. Not least cies’. “That doesn’t say much for what he thinks about because it means working the population…” says the minister. “If I always need It’s about saying, to right across government. to try and persuade and cajole people to come to the Primarolo knows this: health table and say “this is what my organisation can the food producers, “What distinguishes us do to reduce health harm”, then we haven’t quite made to the from the Tories is that they it, we will be trapped in the ‘it’s just a nanny state’ opposed us on the decent mindset. It’s about being on their side, it’s about work - manufacturers, to homes standards, they op - ing with them, and realising it’s a partnership. You can - the advertisers: posed us on health trainers not tell people what to do. You cannot force them, and complained about it, because they won’t do it.” “where’s your they opposed us on our Primarolo says that she is often asked by parents to responsibility to traffic light system for food do things which aren’t strictly in the Department of make sure that labelling and looking at the Health’s gift, such as food labelling or safety on the whole question of the rela - roads: “They say they would love their child to walk to we’re reducing tionship between super - school but are concerned for their safety. Or [they say] harm to health?” markets and the consumer. ‘I want them to be able to play unstructured play out - So they don’t understand side’ but either there aren’t the facilities or again there’s the complexities and the the safety issue. Solving those issues is not the respon - wider public health agenda – that is about health lead - sibility of the department of health. But we can encour - ing but other government departments having a role age it.” too.” So unless the Government finds its way around the Primarolo knows the power of advertisers and big political obstacles of coercion and nanny stateism corporations here. Getting them to change how they (maybe by taking up some of our eight policy propos - operate could make a real difference in improving the als on p14) it might find it hard to make a convincing food that children eat and to tackle childhood obesity public case for being the ‘parent’s friend’. This is partly and improve levels of health. But again, the politics is because people have lost some trust in the state – the tough. When it comes to negotiating with business, this old submissive doctor-patient relationship is now hasn’t been a government that has ever walked with a largely gone, and people are building their own under - big stick. standing of their health. Could one way to make the political narrative work People want a more preventative health service and if be to publicly take the battle to advertisers and super - the government was able to describe a clear vision of a markets? “I think yes, of course we have to - we have ‘preventative NHS’ , they would win enthusiasm and, to take the arguments to them. The idea that the only with any luck, votes. But again there are problems in people who have a duty on alcohol is the Government making the public argument – and this might explain is clearly nonsense. So then it’s about saying, to the why this Government has so far failed to paint that pic - food producers, to the manufacturers, to the advertis - ture. Our polling backs up the idea that people’s judg - ers: “where’s your responsibility to make sure that ments about particular policies are driven by views we’re reducing harm to health?” There are some big about the fairness of the policy itself rather than the levers there: labelling, advertising, access. I do not fairness of the outcome of that policy. This means that think it is acceptable that some in our society think they while people say they want preventive health, they can put their hands up and say ‘this is not my respon - often say they don’t want any of the policies that might sibility, it’s the Department of Health’s’, when a conse - lead to it: “I could be on the television defending the quence of what they are doing is harming health.” government from people who are saying ‘our cancer As can often be true with this government in this rates are too high’. But I could then be on the television frustrating year, ministers sound annoyed at their pow - later saying that we need to cut down smoking and this erlessness, especially over the things that matter most is what the government is doing to take forward initia - to them. “We know we can’t do this by ourselves. How tives to dissuade people from smoking. And as soon as can we compensate for food manufacturers if they I start talking about how to prevent smoking they say won’t properly label what is in their products so people ‘oh no, that’s my individual choice’. So what we’re hav - can’t make the judgements about whether it’s healthy ing to explain is that these are related. Our cancer rates for them to eat it or not? And that means saying to the and our level of smoking are related. Our hospital ad - manufacturers you’ve got a responsibility here and if missions and our liver disease and cardio-vascular dis - you don’t step up to the plate we will point out that ease is related to alcohol consumption.” you aren’t stepping up to the plate…” While, as Primarolo says, “there are those – the Tories This doesn’t seem like much of a threat, and – who say it’s all about personal behaviour, it’s all Primarolo surely agrees. What’s more, the frustration about individual choices and that is so simplistic as to

8 Fabian Review Spring 2008 be laughable,” it is also true that this is a very fine bal - And intriguingly, she is clearly very interested in the ance. Do we just bow to the whim of public opinion or idea of a new ministerial post that focuses on public do we really try to move opinion and thereby change health across government, maybe even from outside of behaviour. One example that the Government rightly the Department of Health, maybe in the Cabinet Office. brags about is the smoking ban, where something that She asks whether a new minister could be the best way had seemed laughably American only a few years ago forward because “I’m increasingly across in every de - became – in a very short partment. And where does the public health minister She is clearly very period – accepted and really sit? I’m increasingly in meetings with three or commonplace. This hap - four other ministers so that we can talk about our joint interested in the pened because legislation departmental issues.” idea of a new was used to actually The politics of health has always been prone to overly drive opinion rather than simplistic stories. For Labour in the 1990s the story was ministerial post that just to react to it. As our clearly one of Tory underinvestment and this morphed focuses on public poll suggests, the pub - easily into a bright new Labour Government that val - health across lic’s appetite for careful ued our hospitals, that was driving down waiting lists nanny statism can be and investing in hard-pressed staff. Eleven years on, government, maybe stronger than we think. though, Cameron’s narrative of waste – an NHS stuffed even from outside of So, if it carefully full of bureaucrats and losing money hand-over-fist – chooses policies that seems to be increasingly attractive to the public. The the Department of make a clear case for pre - fact is, though, that public health has always been more Health, maybe in ventative health – re - complex than that. spondents to our poll But in an election battle between hope and fear, the Cabinet Office particularly liked free maybe fear will win out. Rather than swimming pool access – Primarolo’s preventive, local vision of “the health maybe the Government can make its public case well. service in leading, as a sort of steward, if you like, of But swimming pools or smoke-free zones do not make our health and wellbeing”, maybe we will run on our an election-winning narrative. old friend ‘The NHS isn’t safe in the Tories’ hands’ . Labour MPs know from their own constituencies that “The Tories just don’t get it”, says Primarolo. “They this narrative that connects ends together with means is actually see the health service in terms of buildings and badly lacking on the ground. While people want more they see it frozen in time. The Tories are not responsive local services, they don’t like it when they see it – they to change, whether that be clinical change – listening to feel defensive of their local hospitals. “Big hospitals ab - what clinicians and health solutely have to be reorganised. We’re in the process. professionals are saying The reason they have to be is that people are saying: ‘I about how best to want to get out of hospital as fast as I can and I want to provide health go home as soon as I can, but I might need the support care – or to at home so I want nurse services there. And wherever change in our possible I’d rather have day surgery and I want all the communities treatment to be as close to where I live as possible be - about peo - cause that cuts down the amount I have to travel and ple’s percep - that’s good for the environment and it’s convenient for tion. So they me.’ But it’s when we start to make the big changes see it still as an without explaining and showing and beginning to de - institution, liver the new services that people get unsettled and say rather than as a no, no, no!” living part of our But frustration isn’t necessarily a bad driver. And lives, integrated in our Primarolo has a reputation for getting things done. lives. We know the Tories She’s clearly thinking of creative solutions to joining up aren’t committed to the government better. One more plausible narrative might investment, whatever be the line ‘It’s not just the NHS, stupid’ . The obesity they say.” strategy is already working across a number of govern - ment departments – not just the Department of Health or the NHS. This means Primarolo spends much of her time asking the DCMS what they are bringing to the table on adver - tising, on sport, and on encouraging activity, working with the Department for Schools as the lead department for the health and wellbeing of children, to the Department for Trasnport about cycling and exercise and so on. As she says, “Public health cannot be solved by the Department of Health. It’s everybody’s responsibility.”

Fabian Review Spring 2008 9 HOW LABOUR CAN WIN ON HEALTH

How Labour can win with the NHS

nance initiative, and stand-alone, Not only is prevention of profit-making treatment centres. And the targets that have transformed per - illness more powerful than Dr Neil formance in many areas of the NHS treatment after its onset, it Goulbourne are regarded as unwarranted and Convenor counterproductive interference with is also the most effective of the the decisions of trusted nurses and way of reducing the Labour GP doctors. Network So Labour has a problem. And it is growing inequalities in increasingly clear that the solution health that shame the UK must lie with NHS staff themselves The disappearance of Labour’s impressive and in successfully reconfiguring the and long-unassailable poll lead on health service so that it works to pre - Furthermore, rather than picking a health is frustrating for the vent illness as much as to treat it. fight with health workers as Labour Government. It would prefer that vot - Cuts, privatisation and the under - has tended to (the spat with GPs over ers focused on the extra £50bn a year mining of professionals – the public’s opening hours being the most recent investment, on the 100,000 more staff, view of the NHS under Labour could - example) the Tories have promised to on Britain’s biggest ever hospital n’t be further from its own. It sounds hand back power to staff on the building programme, on the dramatic worryingly like the Tories’ record of ground. Although sharply at odds fall in waiting times for treatment and the mid 1990s. Yet today’s with their record in power, this mes - improvements in performance across Conservatives, having successfully sage appeals both to clinicians who the country. divorced themselves from their record are tired of relentless change and to a But instead the public sees the clo - in government, are now making a public that still trusts health profes - sure of local hospitals and what the convincing bid to become the party of sionals above politicians. media is calling ‘cuts’. Rather than the NHS. Having promised to match If Labour now finds itself wonder - crediting Labour with securing the fu - Labour’s spending plans, they have ing how to recapture the initiative and ture of a valuable public service, neutralised the issue of funding that regain health as an electoral asset, the many recall the introduction of the formed the main dividing line be - solution may be close at hand. It is private sector, through the private fi - tween the parties for years. commonly acknowledged that the

10 Fabian Review Spring 2008 s o t o h P A P focus of the NHS needs to shift if it is to value quality of care over quantity Labour can still regain its to meet the challenges of the years alone. ahead. The crippled health service of Crucially, making that shift – to pre - position as the party of the the 1990s struggled (and often failed) vention not just cure, and to quality as NHS and win the praise it to treat the sick. Having largely well as quantity – means developing a dragged its performance into the 21st fresh approach to NHS staff. The deserves for saving it, but it century, a system designed to deal Government needs to find ways to will only do so if it can first with illness must now face the grow - show that it doesn’t just see staff as ing challenge of preventing it. barriers to reform – but instead sees recommit itself to be the Not only is prevention of illness them as valued resources, and as part - party of the NHS’s staff more powerful than treatment after its ners with whom it can develop the onset, it is also the most effective way new NHS. of reducing the growing inequalities There are some hopeful signs. GPs that it presents a united and success - in health that shame the UK. Inherent can now commission new services ful public face. in the notion of an NHS focused on themselves and more targets are Labour can still regain its position wellness is the need to intervene in being set locally rather than in as the party of the NHS and win the people’s choices, to reduce smoking, Whitehall. But the political message praise it deserves for saving it, but it obesity and physical inactivity. The has not been clear enough. Without a will only do so if it can first recommit two-pronged attack formed by the re - sharper political focus on supporting itself to be the party of the NHS’s staff. cent ban on smoking in public and and empowering staff, the If we cannot convince those working major investment in services that help Government will fail to convince in the NHS that only Labour embod - people to stop smoking are examples those staff and the public that any - ies their ideals, we will struggle to of the way ahead. But to move this thing has changed. convince the wider public. We not agenda still further the NHS must At a time when the Right is once only need the electoral support of that treat patients as individuals – rather more finding an audience for the mes - vast phalanx of NHS staff, we also than as statistics. Only then will they sage that the State should stop med - need them to act as ambassadors for give it license to step into the territory dling in society, Labour must recreate Labour’s achievements, rather than of prevention. For the NHS to become a coalition with the public sector to ef - the disgruntled critics they presently this type of ‘wellness service’, it needs fect progressive change and to ensure tend to be.

Fabian Review Spring 2008 11 vaccination programme has bred indif - ference; as the horrors of vaccine-pre - ventable disease faded from the public mind, they were replaced by un - founded tabloid claims of the MMR vaccine causing autism. The result? Childhood vaccination rates are as low as 11 per cent in inner London, and A shot in the arm cases of measles, mumps, and rubella are rising sharply. Figures released in March show that cases of whooping for health equality cough – which can be fatal to babies – have nearly trebled since 2003. Labour should imitate the successful of the income scale – are 70 per cent US model, introduced by President Mary Creagh more likely to die of cancer than those in Clinton to ensure that no low-income is the Labour the top fifth. For women the difference child was left unvaccinated. There, chil - Member of is 41 per cent. dren can only start school after proof of Parliament for There are also major health inequali - vaccination has been supplied by par - Wakefield, Denby ties between the sexes. Men die ents (except on religious or medical Dale and younger than women because they are grounds). In the absence of vaccina - Kirkburton less robust as babies, more prone to ac - tions, catch-up jabs are offered to chil - cidental and suicidal injury as adults dren before they start school. The and, as older men, less likely to go to responsibility for ensuring children are Children who have not been their GP until their health problems vaccinated by the age of five should fall have become serious. Men’s cancers are to Local Education Authorities, who given their MMR jabs should the poor cousins of breast cancer, men’s have access to 99 per cent of children diets, drinking and cigarette use are ig - through school, rather than health visi - not be allowed to start nored by the lifestyle pages. Looking se - tors or GPs where access can be spo - riously at men’s health, including radic, temporary or non-existent. MMR school, argues accident and suicide prevention, is vital catch-up sessions for five-year-olds are if we are to plug the health inequality standard in some parts of the country, Mary Creagh MP gap between the sexes. but we need to ensure national targets But health inequalities start before are met if we are to offer every child birth and persist in early life. Dealing healthy start. Health inequalities between rich and poor with the recent slide in rates at which We should extend the range of child - are proving hard to eradicate. Figures children are vaccinated would make a hood vaccinations to include chicken released in March by the Department of big difference to health inequality. pox (which can lead to a form of Health show the life expectancy gap be - Vaccination has been hugely success - meningitis), and rotavirus (winter tween men in the poorest areas of ful in eradicating many childhood dis - vomiting disease). We should also in - England and the average man is 2 per eases in the UK. One hundred years clude under-two’s in the annual flu cent wider than it was ten years ago. ago, thousands of children died or were vaccination programme. It is the People born in Wakefield are more left disabled by measles, mumps, and largest vaccine-preventable disease in likely to die of cancer and heart disease, rubella (German measles). Mass vacci - and have a shorter lifespan, than those nation programmes had all but eradi - in Kensington and Chelsea. Men who cated these diseases in the 1980s and earn the least – those in the bottom fifth 1990s. Sadly however, the success of the

After a single rogue study on the links between the combined measles, mumps and rubella vaccine and autism and – perhaps rather more importantly – the media’s glee at whipping up fears, vaccination dropped sharply in the UK from 92 per cent in 1996 to 84 per cent in 2002. By 2003 it was as low as 61 per cent in some parts of London.

With ‘herd immunity’ so compromised, it’s not surprising that children fell ill. Even in 2006, incidents of measles were 13 times their 1998 levels. Mumps cases were a full 37 times higher. In 2006 the first British child in 15 years died of measles and in London two children had to have kidney transplants and their health was permanently compromised. TH

12 Fabian Review Spring 2008 MANIFESTO HEALTH POLICIES POLL Although the medical experts have said there is no foundation for a concern Link benefits to vaccinations about the mumps measles and rubella (MMR) vaccine, over the last five years the rate at which parents vaccinate their children has fallen significantly. Should Another way to increase levels of vaccination would the government do more to raise the number of children who are immunised? be to link child benefit to immunisation and Yes – immunisation only works if everyone is covered 63 vaccination procedures (with exemptions only on No – whatever the experts say, it’s up to families to make this choice 31 clinical grounds). Don’t know 7

The great advantage of linking vaccination to a universal benefit such as child benefit is that you would not be targeting any specific group, but ensuring full coverage. It would also help make the clear argument that this was being done for the public good rather than for this benefit of individuals.

The effect of such a combination of rights and responsibilities, not least to what the medical profession calls ‘herd immunity’, would be great.At a stroke a major indicator and cause of inequalities would be removed.

Sir Sandy Macara

the UK. The virus is more virulent in school meals, the reintroduction from working and reaching their poten - children under two, who should there - of cookery lessons and a ban on tial. Closing the health gap between fore be our first priority. Children are junk food vending machines in rich and poor is an imperative for that also more likely to pass the virus on to schools. And – after pressure to happen. relatives, carers or friends. Vaccinating from children’s food campaign - them would mean less flu in society ers – there is a limited ban on In 2007 Gordon Brown asked overall. Such a programme would junk food TV advertising to chil - Mary Creagh to Chair a bring the added benefits of scaling up dren. Manifesto Group on Public the public health community’s ability We must not be afraid of setting Health, looking at how MPs’ to provide mass flu vaccination which out the need for government inter - experience on public health would be vital in fighting any future vention in public health. Tory policy can be integrated flu pandemic. health spokesman Andrew Lansley into Labour’s next election Labour has much to be proud of in wants to see more money spent on manifesto. ten years of health policy. An end to public health (although he hasn’t hospital waiting lists by the end of this said how the Tories would pay for year, greater access to GPs, earlier de - it while ‘sharing the proceeds of tection and better survival rates for growth’) but he is implacably op - heart disease and cancer. There have posed to clearer food labelling and been great strides in public health too, tighter controls on TV junk food ad - with landmark legislation such as the vertising aimed at children. Labour ban on smoking in public places, the should end the consultations on food ‘five a day’ fruit and veg message, and labelling and place a duty on food man - free fruit in schools. The Healthy Start ufacturers to use the Food Standards scheme has seen a move away from for - Agency’s traffic light system. We mula milk towards vouchers for those also need a 9pm watershed on low incomes to purchase fruit and on junk food advertising. veg, and free vitamin drops for babies Prevention is key. As and toddlers. Labour listened to the we celebrate the 60th Fabian Society’s arguments about sup - birthday of the NHS we port before birth and all pregnant must recognise that for women will receive £120 in the seventh the health service to be as month of pregnancy, to encourage them successful in the decades to to eat healthily and help ensure their come, we must dramatically shift baby is not born underweight. money from hospital treatment to com - The Government is also beginning to munity prevention. We know that give serious attention to the child obe - chronic poor health and poor mental sity problem, with a focus on nutritious health are key factors preventing people 8 POLICIES FOR A HEALTHIER NATION

14 Fabian Review Spring 2008 Give everyone a free pedometer

Anne Campbell 1 Chair of the Fabian Society

Given the rising number of obese adults, an initia - whole family is involved, then the interventions tive to hand out free pedometers to everyone could may be even more effective. pay enormous dividends in reducing future NHS The Government has already shown that using pe - care costs. If this initiative were to run alongside an dometers to promote and incentivise healthy activ - education programme with, maybe, local incentives ity works. In January 2007 Caroline Flint (then a for those users whose activity increases the most, it Health Minister) launched an initiative to hand out could lead to a significant improvement in the pedometers to children in 250 primary schools. An health of the population. earlier government pilot project called Schools on Pedometer users are usually given a target, of say the Move showed a dramatic increase in activity by 10,000 steps a day, which they can do by walking or children at the end of a 23 week programme. This running and this is a good motivation to increase ac - measure would be a cheap way of immediately rais - tivity. ing fitness levels and would provide this govern - Healthy activity is a necessary means of reducing ment with an eye-catching example of how our NHS obesity and pedometers are a very cheap way of en - could work as much as a prevention service as a couraging people to take more exercise. When the treatment service.

Free prescriptions for all

Sunder Katwala and Tim Horton General Secretary and Research Director of 2 the Fabian Society

Making the principles of the NHS part of the fabric nationally and in Britain – that they lead to some pa - of British society is the Labour Party’s greatest his - tients failing to take medicines prescribed to them. toric achievement. We should not take it for granted, (This can also lead to more expensive treatment later). as the US election again sees the world’s wealthiest The King’s Fund makes a strong health argument. nation debate whether it can provide universal The Labour Party should make this a political issue health coverage. too. The 60th anniversary of the NHS should be a time to All major parties claim equal allegiance to the prin - strengthen the core principle of universal access to ciples of the NHS and the Opposition pledges to health services, free at the point of use. We should re - match Labour’s increases in health funding, despite open the argument about whether patients should be backbench grumbling. charged for prescriptions, or whether prescriptions Let us test this. David Cameron has pledged to should be scrapped as Labour has done in Wales. ‘share the proceeds of the growth’, which for him Prescription charges do raise money: around £1bil - means putting tax cuts ahead of investment in public lion a year, which is about 1 per cent of the total NHS services. Labour should share the proceeds of growth budget (though administration would cost less with - via a more popular route: a manifesto pledge to re - out charges). duce prescription charges year on year in the next But charging affects health outcomes. The King’s Parliament, seeking to abolish them entirely as re - Fund health think tank has argued for the abolition of sources allow. This could kick start the ‘popular prescription charges because of the evidence – inter - equality’ agenda Labour needs.

Fabian Review Spring 2008 15 POLICIES

Ban alcohol advertising and sponsorship in sport 3 Dr Howard Stoate Rather Watch any important football match these days on TV, In a bid to assuage critics of the industry’s market - and you’ll see dozens of references to alcohol over the ing strategies the Portman Group has recently agreed ninety minutes. Carlsberg, who sponsor Liverpool, to ban the use of drinks firms’ logos on children’s have become the most popular drinks brand in the replica strips. This is an extremely hollow gesture. country. Their Merseyside neighbours Everton are But does this really matter? Well, the fact is that sponsored by Chang Beer. Carling not only sponsors young people are drinking more than ever. Since 1990 the Carling Cup, but Rangers too. You see drinks the alcohol consumption by 11 to 15-year-olds in firms’ logos on teams’ shirts; drinks adverts on hoard - England has doubled. Alcohol misuse is also having a ings beside the pitch; drinks commercials at half time; growing impact on young people’s health. Teenagers bottles of champagne for the man of the match. The as young as 13 are being admitted to hospital for alco - list is endless. hol-related treatment. And, for the first time, liver spe - Why do we allow this? Britain’s alcohol advertising cialists are now seeing patients in their 20s and 30s rules specify that adverts must not link alcohol with with end-stage alcoholic liver disease. ‘daring’ or ‘toughness’ or suggest that it may enhance We need a more radical measure that will prevent ‘physical performance’. They also say that adverts for alcohol companies from associating themselves alcohol should not appeal strongly to people under with the excitement and glamour of professional 18. And yet it seems that the regulators and the sport and using it to boost their sales among the Government see nothing wrong it seems in allowing young in particular. A complete ban on alcohol ad - our leading football teams and most successful sports - vertising or sponsorship within sport is the only men – with their millions of young fans – to be closely way of achieving this. It is a step that the public will associated with alcohol products. surely welcome.

Reduce the long working hours culture in the UK

Chuka Umunna 4 Labour’s Prospective Parliamentary Candidate for Streatham

It is often said that there is too much emphasis on Numerous studies have shown that blame for our treatment and not enough on prevention when it poor mental health can partly be attributed to our comes to tackling poor health. long working hours culture. It is not a panacea for the One in six people suffers from a mental health prob - resolution of these issues but I’d like to see the com - lem at any one time, so the Government’s announce - plete implementation of the EU working time direc - ment last October that spending on psychological tive setting a limit on the working week of 48 hours so therapies is to increase from £5m to £170m by 2010 is that the 3.2 million people working in excess of those to be welcomed. But the focus needs to shift to reduc - hours every week can lead less stressful lives and per - ing the pressures and strains people find heaped upon haps find the time to exercise, keep fit and healthy, them in the modern world which help create these which would prevent the onset of other health related mental health problems in the first place. problems.

16 Fabian Review Spring 2008 Let local councils make health more equal 5 Bryan Jones

Much of the recent debate about health inequalities in rest with councils. During the nineteenth century it Britain has focused squarely on what the NHS itself was our civic leaders who made some of the single does to tackle them. Far too little attention has been biggest contributions to raising life expectancy that given, however, to the role of local councils in reduc - we’ve seen in this country by building the sewers and ing health inequalities. the water supply networks that remain in our towns If we are serious about reducing health inequalities to this day. then we have to give councils back their public But this changed in the mid 1970s when this re - health role: only by doing this will we bring public sponsibility was transferred to local health boards – a health back into the political mainstream at local decision that robbed councils of generations of accu - level and ensure it gets the priority that it undoubt - mulated public health expertise. edly requires. Today, local authorities are mindful of the impor - We ignore the contribution of local councils at our tance of tackling health inequalities, but it is an issue peril. After all, it is councils that have the responsibil - that comes well down their list of priorities. For ex - ity for planning and maintaining our communities, ample, it is little wonder that thousands of homes get for managing our leisure services and co-ordinating built every year with barely a second thought given as our transport system. In other words they are respon - to how the people who are going to live in them will sible for virtually all the basic infrastructure that live healthy lives. Give local authorities the responsi - shapes our everyday lives. bility and we will see a marked improvement in In fact the responsibility for public health did once health inequalities.

Fewer fast food outlets in town centres

Dr Philip James 6 Hon. Professor of Nutrition, London School of Hygiene and Tropical Medicine

We know that changing your diet makes a big difference. indeed fruit and vegetables must be included within the International evidence shows rapid improvements in price of all dishes in their canteens and catering systems. death rates and levels of disability if people improve (People often don’t buy fruit and veg if they’re sold sep - what they eat. We also know that health education on its arately). We should do the same and ensure that this also own fails. It is crucial that wherever possible we ensure happens in publicly supported organisations – in partic - that only high-quality food is available in public places ular we must eliminate fast food sales from all hospitals, This means biting the bullet and limiting the density of schools, universities, and publicly-funded buildings. fast food in town centres in the same way as we already While we’re at it we could give preference to locally- do for places that sell alcohol. We should also restrict sourced supplies. food and beverage sales within defined zones near Finally, while it is a good thing that traffic light-style schools at specific times of days during school terms. labelling has become much more common in supermar - We must think creatively about how to ensure there is kets, we should also label all meals in restaurants, cafes a better range of food commonly available to people. In and in office canteens with FSA nutritional profiles. This Finland, the Government has engaged business to en - needn’t necessarily mean regulation – we should start by sure that employers are routinely providing good food – publicly identifying the worst offenders.

Fabian Review Spring 2008 17 POLICIES

Make supermarkets put junk food out of 7 children’s reach Tom Hampson Editorial Director of the Fabian Sociaty Anyone who has shopped with small children knows the and top shelf magazines on the, well the top shelf. If they problem. Go to the crisps aisle in Sainsburys, ASDA, or could ask you your race and class at the door and direct Tesco and the provocations to pester power are shameless. you to the relevant aisle, they probably would. High on the top shelves are peanuts, pretzels and the kind Clearly grown ups can fend for themselves, but chil - of dry biscuits for cheese that frankly only those over 60 dren are a different matter. The number of overweight would buy. And on the bottom shelves, Monster Munch, children in the UK has risen steadily over the past 20 years multipacks of Wotsits, and Disney-themed ‘corn snacks’. and around a quarter of young people are overweight or You can’t avoid it – even in the check out queue (the one obese, with many gaining weight from an early age. place in the store where even the most strategically cun - Obesity is associated with many illnesses and is directly ning parent has no choice but to be stationary) the massive linked to lower life expectancy. range of sweets is placed so low down that an adult who The link between child obesity and pester power is an wanted a Mars bar would have to ask a nearby child to obvious one and this is an area where Labour can easily help. play the parent’s friend. Preventative health means asking This is no accident. Supermarkets now employ talented – and then telling – supermarkets to put products aimed professionals to ensure they maximise the exposure that at children on shelves where it is adults who make the individual brands get to their target audience. They put choice. It means local councils’ planning departments en - freshly baked bread near the entrance to draw you in, and suring new supermarkets are built with crèches so single place umbrellas near the exit just in case. They put dips parents don’t have to drag children around the entire next to the nachos and buns next to the burgers. They put store. In the cause of public health, Labour must stand up Transformers magazines at shin level for young people for harassed mothers in Morrisons.

A free bike for your tenth birthday

Louise Bamfield 8 Senior Research Fellow at the Fabian Society

primary school would complement wider cycling strate - Cycling offers multiple benefits both to the individual cy - gies, incentivising local authorities to invest in safe school clist and wider society, from improved health and well- cycling routes and encouraging schools to provide cycle being through increased physical activity, to the wider training, which is currently not compulsory. At this age, a environmental benefits of reduced car use, traffic conges - free bike would also coincide with level 2 training of tion and carbon emissions. Growing recognition of these Bikeability, the modern form of the old style cycle profi - benefits has seen increased investment in a range of na - ciency tests, which gives children the opportunity to un - tional and local initiatives over recent years to create the dertake quality cycle training to ride safely on roads. conditions in which more people are cycling more safely Of course, choice and flexibility within the scheme and more often. would be essential – there is no point in handing out na - Along with a free pedometer, giving all children a free tional-prescription bikes for children who already have bike at the beginning of Year 5, when most pupils are them, or cannot store them. A free bike would therefore about 10 years old, would provide the boost needed to re - be one of a number of alternatives ways of spending a ally bring about behavioural and lifestyle change for the voucher, which could also be used to buy cycling acces - current and next generations of young people. Giving sories, other sports equipment, or a short course of out - every 10 year old the chance to cycle in the last years of door activities.

18 Fabian Review Spring 2008 POLICIES THE FABIAN ESSAY

Sir Michael Marmot is chairing the WHO’s REDUCING Commission on Social Determinants of INEQUALITIES Health which will report this spring. Here he argues that IN HEALTH: to reduce inequality, government must be A POLICY much more joined up

Michael Marmot is Professor of CHOICE Epidemiology and Public Health at UCL

Here’s an unsurprising statement: poor people have poor health. As Figure 1 Map of male life expectancy in Camden one simple illustration, Guatemala is poor and life expectancy for men, there, is 66.2. By contrast the UK is rich (GDP per head in the UK, at real exchange rates, is $33,200; in Highgate Guatemala, under $4,600) and has Hampstead a male life expectancy of 76.7. An 11 Town Frognal year difference in life expectancy is and enormous. Fitzjohns Gospel If you want to see a life ex - Fortune Green Oak pectancy difference of 11 years West and don’t want to enlarge your Hampstead carbon footprint, or lose your Belsize Haverstock Cantelowes bags at Heathrow, get on your Swiss Cottage bike. I live and work in the Camden Town wit Primrose Hill and, Kilburn St Pancras and more or less happily, can cycle Somers from Hampstead in the north of Town the borough to St Pancras and Regent’s Somers Town in the south in 30 Park King’s Life expectancy, males (in years) Cross minutes. In that time I have cov -

ered a life expectancy gap of 11 77.5 to 79.7 Bloomsbury 75.5 to 77.5 Holborn and years. If I were being trite I might Covent say that Hampstead is the UK and 73.5 to 75.5 Garden Somers Town is Guatemala, yet 71.5 to 73.5 69.5 to 71.5 they are only 8 Km apart rather than 8,000. I started by saying that poor Source: London Health Observatory people have poor health. But are

Fabian Review Spring 2008 19 THE FABIAN ESSAY

jobs with low risk of unemploy - Figure 2 Whitehall gradient – absolute difference in mortality by grade and age ment, there was a social gradient in health: people second from the top had worse health and shorter 80 expectation of life than people at

70 the top of the hierarchy. Those third from the top had worse 60 health than those second from the top; and so on all the way to the 50 bottom. (Figure 2)

40

30 Poverty and inequality The stark truth is that health in - 20 equalities represent the major pub - lic health issue facing the UK and 10 most other countries. But the so - 0 cial gradient should change the

40-65yrs 65-89yrs 70-89yrs debate. No one is in favour of poverty. If the poor have poor health as a result of their poverty, Admin Prof/Exec Clerical Other that provides yet one more reason Source: Marmot MG, Shipley MJ (1996) . Do socioeconomic differences in mortality persist after to deal with poverty. Surely all po - retirement? 25-year follow-up of civil servants from the first Whitehall study. BMJ, litical parties would sign up to 313(7066):1177–1180. that. The social gradient, however, has two key implications. First by Wilkinson’s the people of Somers Town and focussing only on the poorest, one misses people sec - St Pancras poor? Forty per cent ond from the bottom who have worse health than those conclusions – of the global population are above them. In fact one misses almost everyone with that inequality poor: they live on $2 a day or health disadvantage due to social position because we less; and in Guatemala 32% of all have worse health than those above us in the social affects the the population do. hierarchy. The social gradient means that we are all in - health of the By this definition no one in volved in this issue. It is not “them”, the poor, and Somers Town is poor, although “us”, the non-poor, but all of us. This leads to the sec - non-poor as they are certainly a good deal ond implication. The social gradient in health tells us well as the poor less well off than the people of that health inequalities result from the unequal distri - Hampstead. Yet their expecta - bution of resources in society not only from an unfor - – have been tion of life is a staggering 11 tunate few who are poor. The “poor” of Somers Town hotly debated. years shorter than people up and St. Pancras are at one end of a continuous distri - the hill in Hampstead. What is bution. They are not qualitatively different from resi - But there seems going on? dents of Kentish Town. They simply have a bit less of little doubt that Before answering the ques - what is good for health and/or a bit more of what is the degree of tion of what is going on and, bad. I’ll come to that in a moment. more importantly, what we can This changes the political debate. Eradicate poverty? inequality does do about it, it is crucial to A noble aim. I, and most others, applaud. Eradicate in - matter for health recognise that the statement equality? The nay sayers are now varied and numer - about poverty and poor health ous: impossible, or undesirable, or both. is, at best, a partial picture. The map in Figure 1 shows fine gradations of life expectancy within the borough of Camden. It is not simply that people in the poorest The magnitude of the social gradient areas have poor health and everyone else is fine. There is a social gradient in health. in health varies My colleagues and I first showed this social gradient It is, of course, true that all societies have hierarchies in health in the Whitehall studies of British civil ser - which correspond to unequal distribution of resources. vants. In Whitehall, among office workers, none of No one has succeeded in abolishing social inequalities. whom is poor in the global sense, all of whom had sta ble This does not for one moment mean that we should

* These Figures come from Tackling Health Inequalities: 2007 Status Report on the Programme for Action.DH 2008. The production of this report was overseen by the government’s Scientific Reference Group on Health Inequalities which I chair.

20 Fabian Review Spring 2008 THE FABIAN ESSAY

births. In England Figure 3 Poverty pre and post tax and benefits the most disadvantaged group, sin - gle mothers who have never worked or are long-term unem - 45 ployed, have infant mortality of 40 54 10/1000 live births. For those as - 35 49 50 signed to the “low” socioeconomic 72 62 63 30 71 classification – routine and manual 24 25 71 59 44 – the infant mortality is now * 20 5.6/1000 live births. Fogel says that the next great challenge is egalitari - 25 anism of quality of social and psy - 10 chological resources. He uses the 5 term ‘spiritual; I use the rather more 0 researchy ‘psycho-social’ – by which s y y y a S K n n d l i m a d n d e n U U a a u a n t a a i d w I l p I mean the degree of control people a r n e g l m S n l r a o i r w e e F C e N S B

h have over their own lives and their G t e

N opportunities for full social partici - pation – but we are talking about

Poverty rates post tax and transfers Poverty reduction by income redistribution the same thing. Increasing income inequality, the incomes of the rich growing Source: Lundberg et al 2007 citing Fritzell and Ritakallio 2004. Data from Luxembourg Income Study more rapidly than those of the poor, means that some have more compared to others: relative in - come inequality grows even as ab - therefore ignore health inequalities. The magnitude of solute standards of living improve. health inequalities varies within a society over time Economist/philosopher Amartya Sen provides insight and varies across societies. If the social gradient in into how income matters. Relative income is important, health is not fixed it is a reasonable question to ask he says, because it translates into absolute differences what we can do to change it. in people’s capabilities to lead a flourishing life. The most intrusive question, then, is whether the de - What are we all saying: spiritual? Control over your gree of inequality in society matters. Richard Wilkinson life? Capability to lead a flourishing life? Being a social has argued powerfully that it does; that the greater the participant? A dispassionate observer might ask if these degree of income inequality the worse the overall should be in the realm of policy. Of course it should. health of society and the higher the rates of crime and Being relatively poor means that a flourishing life is social disorders. Wilkinson’s conclu - sions – that inequality affects the health of the non-poor as well as the Table 1: Male life expectancy: Glasgow, Washington DC, and selected poor – have been hotly debated. But countries there seems little doubt that the de - Place Life expectancy at birth, (male) gree of inequality does matter for health. Scotland, Glasgow (Calton) b 53.9 Income matters but not for the rea - India a 62.3 sons it does in Guatemala where the United States, Washington D.C. (black) c 62.5 a poor lack clean water, adequate nutri - Pakistan 64.3 Lithuania a 66.9 tion, reasonable shelter and quality Philippines a 68.9 medical care. As the American econo - Poland a 71.0 mist Robert Fogel says in describing Mexico a 73.1 the US scene: there are now more ra - Koreaa 74.3 a dios in the US than there are ears. The United States 75.2 Cuba a 75.8 poor own automobiles and are a 76.7 plagued by obesity rather than calorie Japan 78.7 shortage. Material deprivation, in the Scotland, Greater Glasgow (Lenzie) b 79.5 $2 a day sense, is over in the US as it is United States, Montgomery Country (white) c 79.5 in Britain. To see that, look at infant Iceland 79.9

mortality rates. Infant mortality is ex - a Country data: 2005 data from Human Development Report (UNDP 2007) quisitely sensitive to material depriva - b pooled data 1998 – 2002: Hanlon P, Walsh D, Whyte B (2006) tion. In Guatemala the poorest 20% c pooled data from 1997 – 2001: Murray et al. (2006) have infant mortality of 58/1000 live

Fabian Review Spring 2008 21 THE FABIAN ESSAY less open to you. You have less control over your life, that there remain differences in fewer opportunities to be a full social participant, and The NHS is a access and use, in different so - health suffers as a result. representation cioeconomic or ethnic groups, of social these should be ironed out. Policy matters But differences in health care Figure 3 shows the impact of policy on poverty. It uses capital. It is are not the main reasons for the a relative definition of poverty, as we do in the UK – there for occurrence of social inequalities below 60% of median income. It shows that before taxes in health. Health inequalities and transfers poverty levels in the UK are higher than everybody. To arise because of differences in in the US and a little higher than in Sweden. Taxes and the extent that the causes of illness. Armed benefits reduce poverty levels in the UK by 50%. This is with that insight, it is then com - better than in the US but pales by comparison with there remain mon to focus on individual be - Sweden, Norway and Finland where government pol - differences in haviours: smoking, obesity and icy reduces poverty levels by more than 70%. Absolute alcohol. I chair the Commission deprivation may be finished in the UK but relative access and use, on Social Determinants of poverty affects what people are able to do in society. We in different Health set up by the World have a choice. Do we want a society with higher levels Health Organisation. We use of poverty such as the US or one with lower levels such socioeconomic the phrase: “the causes of the as in the Nordic countries. It gives different meaning to or ethnic causes”. Smoking and obesity choosing health. are potent causes of illness and Parenthetically, the US has lower life expectancy and groups, these make important contributions worse health than we do. In fact, in terms of life ex - should be to generating inequalities in pectancy up to age 65 the US ranks 33 globally for men ironed out. health. But why are there in - and 36 for women. I would not be so scientifically equalities in smoking and obe - crude as simply to attribute the comparatively poor sity? What are the causes of these causes? Our answer health in the US to their miserly approach to the rela - is, along the lines of the above discussion, that the tively poor and disadvantaged. What one can say with causes of the causes lie in the circumstances in which confidence is that their approach does not appear to be people are born, grow, live, work and age – the social benefitting them much, as illustrated by Table 1. In determinants of health. terms of health, the poorer parts of Glasgow and This implies that action to reduce health inequalities, Washington DC are worse places to live than many while involving the health sector, must involve the countries at much lower levels of income. To accentuate whole of government. I have already given the example the point that social inequalities in health are not only of policy on taxes and benefits. Two more examples about money, 80% of India’s population live on $2 a make the point. day, yet average life expectancy is better than in the We know that the higher the education of parents the poorest part of Glasgow. greater is the literacy of young people. Literacy mat - The nature of tax and benefits also matter. Regularly, ters, of course, for life chances including: income, the the Office of National Statistics produces a splendid re - type of job, and whether you live in Somers Town or port on the effects of government fiscal policy on dis - Hampstead. These, in turn, will contribute to health in - tribution of income. It has three major messages. First, equalities. The data show that there is a gradient in the income tax and transfers are strongly progressive: they link between your parents’ education and your own lit - redistribute income to the benefit of those worse off. eracy competence. But the steepness of the gradient Second, consumption taxes are clearly regressive. varies. The impact of parents’ education is much Consumption taxes have the advantage that they may stronger in the UK than it is in Sweden or, not shown, be “green” or discourage smoking and drinking but in Japan. We are failing our children. Some of that may they are regressive and hurt the incomes of those lower be to do with the quality of schools but it starts with down the income scale, relative to those higher up. family environment, and early pre-school child devel - Third, distribution in kind – for example health care opment, which is affected by the circumstances in and education – has progressive effect. Governments which the parents live and work. Surely it should be a can do a great deal. Witness the present government’s major policy aim to try and break the link between par - commitment to reduction in child poverty. As a result ents’ circumstances and the literacy levels of their off - 600,000 fewer children are in poverty. spring. The other example comes from work. Occupational diseases, in the sense of exposure to chemical and phys - More than health care ical hazards, remain a concern. But the major contribu - I am guessing, now, but I suspect that most of us who tion of work to health is in the diseases that we don’t work in the health sector in the UK have a strong, even usually classify as occupational: mental illness, muscu - passionate, commitment to a national health service loskeletal disorders, heart disease. Here, there is abun - free at the point of use. The NHS is a representation of dant evidence that the psychosocial work environment social capital. It is there for everybody. To the extent matters. We have shown strong effects on illness risk of

22 Fabian Review Spring 2008 The Commission three types of occupational ex - posure: jobs characterised by Fabians: setting the health agenda on Social high demand, low control and Determinants of little support at work; imbal - The Fabian Society celebrates the 60th anniversary of ance between efforts and re - the NHS, having being the first to call for its creation Health argues, wards; low organisational following WHO, justice at work. Singly and to - and having consistently set the political and policy gether these make a major con - agenda on health. that health tribution to preventable illness inequalities that in working age populations.  1911 The Fabian tract A National Medical Service These are in addition to the are avoidable makes the first call for free universal healthcare, health hazards of unemploy - building on ’s 1909 Minority Report are inequitable, ment and insecure employ - on the Poor Law. ment. These psychosocial risks unfair. Putting can all be influenced by man - them right is a agement policy. We do not  1968 Leading Fabians Richard Titmuss, Brian Abel- simply have to accept them as Smith and Peter Townsend – who have set much of matter of social an inevitable part of a complex the post-war health policy agenda in their work at justice work scene. the LSE – challenge the government to link health, welfare and poverty policy in their Socialism and Who cares about health inequalities? Affluence Fabian lectures and book. We all care about health. The Commission on Social Determinants of Health argues, following WHO, that  2000 The Fabian Tax Commission’s call for health inequalities that are avoidable are inequitable, un - hypothecating extra taxation to increase health fair. Putting them right is a matter of social justice. But min - spending sets the agenda for the government’s £8 isters of education, transport, industry, finance might argue billion increase in health spending by increasing that health is not their business. Health is for the Secretary national insurance in the 2001 budget. of State for Health. It is for him but, given the social deter - minants of health, health inequalities are also for the whole  2002 Howard Stoate’s A ll’s Well That Starts Well of government. Ministers in other departments should care makes an influential call for a national obesity because improvement in health and reductions in health in - equalities are clear signs of social progress. We know things strategy. Several ideas such as cookery lessons in have got better in Britain, generally, because the health of all schools are adopted. Others – like banning pre- social groups has been improving. There remains a contin - watershed advertising – remain on the campaigning uing significant challenge: now, to make progress in reduc - agenda. In 2006 Stoate’s follow-up pamphlet ing health inequalities. Challenging the Citadel sets out a strategy to make the shift to public health possible.

1. Marmot M, Status Syndrome, Bloomsbury London 2004 2. Tackling Health Inequalities: 2007 Status Report on the Programme  2006 The Fabian Life Chances Commission for Action .DH 2008. 3. CSDH Interim Statement (2007) Achieving Health Equity: from root analysis of inequalities at birth leads to Gordon causes to fair outcomes, Commission on Social Determinants of Brown reforming child benefit so that it is paid from Health http://www.who.int/social_determinants/resources/ interim_statement/en/index.html the 29th week of pregnancy. 4. Image from: WWW.CAMDENPCT.NHS.UK/YOUR_HEALTH/LIFE EX - PECTANCY.HTM Data from London Health Observatory: 2007 Louise Bamfield’s Born Unequal continues the www.lho.org.uk/DataAndMethods/PCTIndicators.htm  5. Marmot MG, Shipley MJ (1996). Do socioeconomic differences in push for better support for pregnant mothers, with mortality persist after retirement? 25-year follow-up of civil servants government responding with the new Maternity from the first Whitehall study. BMJ , 313(7066):1177–1180. 6. Lundberg O, Yngwe MA, Stjarne MK, Bjork L, Fritzell J (2007) The Support Grant to improve nutrition in pregnancy. Nordic Experience: Welfare States and Public Health (NEWS) Report for CSDH, Stockholm, Centre for Health Equity Studies (CHESS) 7. Fritzell, J. & Ritakallio, V-M. (2004) Societal Shifts and Changed  2008 The Fabian health inequalities forum, with Sir Patterns of Poverty . LIS Working Paper Series, no. 393. Luxembourg Michael Marmot and others, and this special Fabian & Syracuse, NY. 8. UNDP (2007). Human development report 2007/2008.Fighting Review set out new ideas as we seek to shape the Climate Change: Human solidarity in a divided world . New York, next decade agenda with new ideas for the next NY, United Nations Development Programme. manifesto. The Fabians are also looking to 9. Hanlon P, Walsh D, Whyte B (2006). Let Glasgow flourish . Glasgow, Glasgow Centre for Population Health. commission a new Fabian Ideas pamphlet on health. 10. Murray CJL et al. (2006). Eight Americas: investigating mortality dis - parities across races, counties, and race-counties in the United States . PLoS Medicine, 3:1513–1525.

Fabian Review Spring 2008 23 Books Editor: BOOKS Hannah Jameson

ment, but it must be complemented by a greater focus on rights and justice. Collier says relatively little about these. Where he is on stronger ground is in his suggestion that the ‘bottom billion’ countries present formidable and gen - 58 countries uinely new development challenges. The international policies that might help these countries make progress in falling apart development go far wider than the tra - ditional aid, debt relief and trade agenda. No amount of development as - In The Bottom Billion, Paul Collier makes an sistance will make much difference to the long-suffering people of Somalia un - incomplete case for tackling poverty, less there is real movement towards a political resolution of the conflict and says David Mepham the development of some functioning political and administrative institutions. Collier’s argument is that the coun - tries of the bottom billion remain Paul Collier is a controversial figure, wider range of policy instruments to re - caught in a series of development traps. particularly amongst some develop - duce poverty. He focuses on four in particular: con - ment non-governmental organisations Collier’s core thesis is a simple one. flict, natural resource wealth, geogra - (NGOs), and he clearly enjoys being The problem is not the five billion peo - phy, and bad governance. provocative. Don’t look to NGOs to ple who live in what are still called de - Seventy three per cent of the people help solve the problem of global veloping countries. Many of these in the societies of the bottom billion poverty, he suggests in the first chapter; people, he suggests, have already made have recently been through a civil war they are more interested in moralising or begun the transition out of acute or are still in one. Even where they and keeping their messages simple poverty thanks to economic growth. emerge from civil war, there is around a than in developing a credible policy This contrasts with the situation of fifty per cent chance that they will slip agenda that would benefit the world’s around a billion people (largely but not back into violence within five years. poor. They generate ‘development exclusively African) who live in 58 These conflicts are hugely destructive buzz’, but are ‘at times a headless heart’. countries that are ‘falling behind, and and a major barrier to countries lifting While some development NGOs will often falling apart’. This is where Collier themselves out of poverty. The conflict bristle with indignation at this, Collier is argues that the focus of global develop - trap is unlikely to be overcome without too credible a figure to be ignored. ment efforts should now be. greater international support for con - Currently the Head of the Centre for the Is Collier’s proposed framework use - flict prevention, resolution and peace - Study of African Economies at Oxford ful? Well, yes and no. It seems unhelp - building. University, formerly a Director of ful to suggest that there is not a He highlights next a natural resource Research at the World Bank and adviser development problem in countries out - trap - a tendency for abundant natural to the British Government’s side the bottom billion, or, to be more resource wealth to fuel corruption and Commission on Africa, he deserves to specific, not a development problem patronage rather than foster growth be taken seriously. NGOs should en - that the world’s richer countries should and development. Through initiatives gage with Collier’s argument and re - spend much time worrying about. 80 like Publish What You Pay (a campaign spond to his criticisms by developing per cent of the world’s poor may live in pressing extractive industries to publish the very policy agenda he claims they countries that are developing, ‘often at their resource payments to national lack. Providing a measured critique of amazing speed’, but it is a big leap to governments), NGOs have been on this Collier’s latest book would be a good suggest that the elimination of acute case for some years. But Collier is right place to start. poverty is a done deal. Look at India. that there is more to do to help the poor - The Bottom Billion is well written, un - Despite high rates of economic growth est countries manage their resources ef - derpinned by a mass of economic for over a decade, the country’s poverty fectively, so that large-scale oil or gas analysis, and makes a powerful argu - levels remain stubbornly high, includ - reserves become a blessing not a curse. ment for re-conceptualising our ap - ing shocking levels of maternal and A third trap is to be landlocked and proach to development. At a time child mortality. bordered by ‘bad neighbours’ (30 per when the development debate has be - One explanation is the persistence of cent of Africa’s population is estimated come unhealthily polarised between entrenched inequalities, including the to be in this category). Collier suggests champions of aid like Jeffrey Sachs and caste system, that prevent poor families that these conditions can be a major im - its harsh critics such as William Easterly, from improving their income, health, pediment to countries trading their way Collier offers a more nuanced and so - education and nutritional status. What out of poverty. Addressing this obstacle phisticated narrative that recognises the is true of India applies more widely. is complex, although greater invest - role of aid but also the need for a much Economic growth is vital for develop - ment in transport infrastructure can

24 Fabian Review Spring 2008 BOOKS

play a role. This is an issue that many and shift into value-added exports. process than NGOs and governments NGOs have neglected. Tailored support may be required to as - have often been prepared to acknowl - Lastly, Collier focuses on the conse - sist diversification strategies in these edge. In the countries of the bottom bil - quences of bad governance, particu - countries and to help meet the chal - lion and more broadly in the larly in smaller countries. Three lenge that China represents. developing world, progress in reducing quarters of the population of the bottom Secondly, there is the impact of cli - poverty requires greater support for re - billion live in countries that are or have mate change. Collier acknowledges formist elements in the countries con - been failing states. It is extraordinarily that geography can shape development cerned, those who are pushing for more difficult to break free from this trap: he options, but he says relatively little accountable government, action against estimates the chances of any one coun - about the extent to which the world’s corruption, and greater attention to the try doing so each year at just 1.6 per richer countries are primarily responsi - needs of the poor. Though both sides cent. Collier makes a number of pro - ble for climate change and how this will be loath to admit it, on this issue posals, worthy of further study. For damages the development prospects of and many others, mainstream develop - NGOs, more thinking is needed on how the world’s poor. Collier argues that de - ment NGOs and Professor Paul Collier to provide assistance to poor people liv - velopment traps are rooted largely in are not so far apart. ing in dysfunctional polities and how to the countries themselves and that exter - support those elements of civil society nal support is needed to assist countries trying to rebuild state institutions and to break free of them. But the issue of David Mepham was the principal establish basic services. climate change shows that wealthier author of a recent Save the Children While these four traps do present real countries are also part of the problem report on child mortality: Saving obstacles to development in the poorest and need to put their own house in Children’s Lives – Why Equity countries, they are not the only ones. It order. Matters would be possible to construct a much Collier ends his book with a rallying longer list of development traps. Two cry that would not look out of place in a The Bottom in particular are worth flagging here. NGO campaign pamphlet. ‘Within the Billion Firstly, there is what might be called societies of the bottom billion there is an Paul Collier the ‘late developer trap’. Stimulating intense struggle between brave people economic activity is challenging who are trying to achieve change and enough for the countries of the bottom powerful groups who oppose billion, but the existence of a highly them…To date, we have largely been competitive low-cost producer like bystanders. But our support can be de - China makes it harder still for these cisive’. He is right. Development is a £16.99 countries to diversify their economies more political and less technocratic OUP

Fabian Review Spring 2008 25 BOOKS

of complex coexistence amongst ism and the fall of the Islamic em - Jew, Christian and Muslim: Muslim pires is clear: Muslims “met the tolerance in periods of unques - challenges of dominance; they are tioned dominance but some harsh still struggling with the challenges treatment when People of the Book of defeat.” (p. 197) were seen as a threat: Medina, Karabell continues throughout Damascus, Baghdad, Andalusia history to bring us up to date with and the Ottoman empire provide the situation today, influenced by a ample examples. One of Karabell’s myriad of historical influences. The loudest messages is that it is often Islamic reformist and nationalist the conflicts only that are remem - movements over the last two cen - War bered, on all sides, whilst the glori - turies are every bit as complex and ous accomplishments of interesting as the phenomenon of co-operation are forgotten and dis - Zionism. Modern nation states in and appear like a mirage – this collec - the Middle East have their own pe - tive amnesia must be reversed if we culiar dynamics with religious are serious about peace between colouring, whether Egypt, Israel or faiths in our world. Jordan: the Jewish state, like almost peace Memorable and fascinating en - every Muslim country, has funda - counters during this history include mentalist-secularist tensions. It is In a narrative spanning the summoning of the Nestorian an obvious mistake, although many patriarch Timothy I to the palace of fall into it, to reduce conflicts in the 14 centuries, Al-Mahdi in Baghdad, c. 780 CE, to Middle East to simple faith-based debate theology with the caliph crusades or jihads. Usama Hasan finds a himself. Half a century later, the The book ends with a provocative episode is repeated with the Greek chapter entitled, “Is Dubai the new understanding of orthodox bishop Abu Qurra and Future?” to which my answer Caliph Al-Ma’mun but then would be: perhaps, but with much Islam and the West Nicephorus, Emperor of less materialism. There needs to be Byzantium, and Harun al-Rashid deeper philosophical and theologi - exchange insults by correspon - cal contact also, as there was for dence. The Christian Cordoba mar - centuries. The phrase “Islam and “People of the Book” ( Ahl al-Kitab ) is tyrs give their lives to proclaim the the West” in the title is itself prob - th e Koranic term for religious com - superiority of their faith amidst the lematic, given the rich religious, munities outside that of the Abrahamic glory of Andalusia that philosophical, political and cultural Prophet, whose message is re - produces both Averroes and interactions that the author master - garded as merely the final form of Maimonides. The latter, who re - fully describes, but the author is Islam – submission to God alone. mains a towering medieval Jewish surely right in his conclusions: “If People of the Book are those who thinker, theologian and philoso - conflict is what we want to see, cling to scriptures and prophets re - pher, also serves as personal physi - there is conflict. But if peace is vealed or sent by God prior to cian to none other than Saladin what we are looking for, then peace Muhammad. The term has prima - himself, the Muslim hero of the is there to be found … Peace is rily been applied to Jews and Crusades. Meanwhile, the Turkic woven into our collective past; it is Christians, although it also partly Khazar tribe of modern-day Russia there to be seen in our messy pres - included Zoroastrians in early chooses monotheism and converts ent; and it will be there in our Islam, and there was even the sug - to Judaism, at least partly in order shared future.” (pp. 285, 291) gestion in later Islamic history that to avoid being caught in direct con - Hindus could perhaps be covered flict between neighbouring, com - by this term, given their scriptures peting Christian and Muslim Usama Hasan is Director of the City that also speak of Divine realities empires. Such rich encounters are Circle, London. and higher truths. This Koranic de - sadly unthinkable in parts of scription of people of other faiths is today’s world that are characterised People of one of respect as well as responsi - by polarisation and mutual igno - the Book: bility: the respect allowed a domi - rance and hatred. The Forgotten nant Islamic civilisation to include The Ottoman millet system of self- History of Islam non-Muslim subjects with immense governing faith communities is fas - and the West generosity overall; the responsibil - cinating, though complex and Zachary ity is upon all people of faith to be problematic – echoes of it may have Karabell true to God’s word been heard by some in “that recent Karabell eloquently narrates the lecture” by the Archbishop of £9.99 millennium-and-a-half-long stories Canterbury. The legacy of colonial - John Murray

26 Fabian Review Spring 2008 BOOKS

The problem is that the upward trend and France have relatively lower rates of in distress levels could as easily be ex - declared distress may be due in part to plained by the growth of what might be the continuing, if declining, influence of called the ‘stress industry’, the expan - Catholicism in maintaining family sion of the counselling and psycho-ther - structures and social coherence as much apy professions and along with them as their adoption of a more unselfish the lifting of the stigma and prejudice as - model of capitalism. There is also the sociated in the past with the admission awkward issue of China’s relatively low of depression and anxiety. This will level of reported distress alongside its have led to an increase in the numbers own transition to consumer capitalism, of people saying yes when asked if they a snag dismissed as due to the rot not Stress suffer from emotional distress in self- yet having set in. defining surveys and may well account While James’s fundamental case is for most of its rise. James of course is unproven that does not mean all is right part of this industry himself, both as a with the model of consumer capitalism balls practising clinical psychologist and as a that he targets. The rise of mass afflu - campaigner and polemicist. ence once offered the prospect, perhaps Moreover to accept the thesis we naively, of more leisure, more choice Stewart Lansley is would have to believe that Britons expe - over lifestyles and an end to both ab - rienced much less emotional upheaval solute and relative poverty. Instead, unconvinced by Oliver in the immediate post-war decades, Anglo-Saxon capitalism has become in - that, for example, women often trapped creasingly dependent on rampant con - James’ ‘selfish capitalist’ in unhappy marriages and lacking the sumerism despite the growing evidence greater economic independence and ed - of the weak link between well being and ucational and professional opportuni - material living standards. This is a provocative book but one that ties they enjoy today were much The rise of affluence has brought im - promises more than it delivers. James’s happier then their counterparts today? proved living standards for all along central contention is that the move from The second set of data is drawn from with wider opportunities in work and what he terms ‘unselfish’ to ‘selfish cap - a study by the World Health education for the majority and few italism’ in English-speaking nations has Organisation into the level of distress would opt to return to the limited led to a surge in the level of mental ill - across a number of nations. This seems lifestyle options available to earlier gen - ness since the 1970s. He attributes this to show that distress is sharply higher in erations. But affluence has also brought trend to the spread of ‘relative material - Anglo-Saxon developed nations than the commercial exploitation of children, ism’ (or the ‘affluenza virus’ that was the elsewhere with the US at the top of the the over-rewarding of business and City subject of his previous book) and its ob - table. The conclusion from this data is executives, the idolising of the super- session with money, possessions and less easily dismissed but again there are rich and a return of levels of wealth and fame. questions about James’s interpretation. income inequality not seen since before James attempts to prove that the ad - First there is the somewhat funda - the Second World War. To date the po - vent of selfish capitalism has brought a mental problem that the UK, Australia tential offered by rising material wealth rise in emotional distress by drawing on and Canada are not part of the WHO to bring greater equality and well-being two data sources. The first is a set of study. To include these countries in the has yet to be harnessed. It is this para - sample surveys of levels of emotional comparison James draws on other and dox of prosperity that is one of the most distress at different points over the last by his own admission, non-comparable, intractable challenges facing Britain 30-40 years in the US and the UK. These data. Moreover some of the differences today. show much higher levels of contempo - between nations can be explained by rary distress than in the past. cultural differences. That Spain, Italy Stewart Lansley is the author of Rich Britain, The Rise and Rise of the Super- Rich . His book Londongrad will be FABIAN QUIZ published in September. For the first time in history Asia will contain three large, economi - cally powerful countries, all with interests and ambitions that range across the whole region, and the world. Rivals: How the power The Selfish struggle between China, India and Japan will shape our next decade , by Bill Emmott will explore the legacies of history, the Capitalist likely future trajectories of China, Japan and India, and the poten - Oliver James tial collisions which will shape the 21st century. To win a copy of the book, answer the following question: Q: Who was the Secretary of State for Health when the NHS was founded in 1948?

Please send you answers on a postcard, postmarked no later than 15th February 2008 to 11, Dartmouth Street, London, SW1H 9BN. £9.99 Or, email your answer to [email protected] . John Murray

Fabian Review Spring 2008 27 of women’s lives as it is about sys - temic change – our discussions have not just been about process and pro - cedure. Almost straight away, they take on a personal perspective, focus - ing on how women juggle much in life, and the challenges they face in making a public commitment. And it is clear that roles could sometimes be more challenging than some of our participants had expected – that When the personal progress was much slower. There is also a gap between what women expect from taking part in becomes political public life, and what the experience is really like. Involvement in public life can come at a high personal make up just over a third of public cost. It is not unusual for council - appointments. lors, for example, to do case work This matters – we know that if rep - late into the evening and over resentatives are not as diverse as the weekends. Seema Malhotra populations they represent it can re - What’s more, asking for help or ad - is Director of the duce the quality of debate and re - vice when you are older can be a dif - Fabian Women’s duce legitimacy. We need to make a ficult thing to do. Within the Fabian Network real step change and that means fo - Women’s Network, even women cussing not just on how our systems who have achieved senior positions need to change in terms of proce - in their fields say that if they had had We need to take a radical dures and processes, but taking a re - routes through which to ask for ad - newed look at the lives of women, vice and mentoring, they would have new aproach to get more and on what they want. achieved their positions far earlier This is why the Female Futures pro - and with much less struggle. This is women into public life – and gramme, run by the Fabian Women’s one reason they are so keen to be part Labour has to take the lead, Network, has been exploring the ex - of a process that means they can sup - perience of women today. What en - port younger women today. says Seema Malhotra courages women to take a step into This is a year of important anniver - public life, and what happens to them saries. Ninety years ago, in 1918, when they do? Women of all ages, women won the battle for the vote backgrounds and levels of engage - and were finally able to stand for the We should be in a golden age of ment have participated in round table House of Commons. In 1928 men women’s participation in public life discussions with female MPs at the and women over 21 were granted the in Britain. Great progress has been House of Commons. We have partici - right to vote in the Equal Franchise made – and our democratic systems pants in their fifties who are consider - Act, and in 1958 women were al - are transformed as a result. There is ing public life for the first time and lowed to become members of the no doubt that the Labour some in their twenties who have al - . What’s more, this Government has a strong record on ready been elected as councillors. The year also marks the 100th anniver - inclusion and representation in poli - MPs have been open and frank about sary of the founding of the first tics, and has invested considerable their personal experiences. Fabian Women’s Group. resources to boost engagement in It has been clear from these discus - Parliament now has more women public life. Our equality bodies and sions that there is a real lack of than ever before, though the record institutions are being revolutionised, awareness about the public roles that of individual political parties is with the new Equality and Human women could consider. Although highly uneven – 76 per cent of female Rights Commission and the women are now taking part in far MPs are Labour. And women can cel - Government Office for Equalities. more community activity – just ebrate progress the world over. Over Yet less than 20 per cent of MPs under 50 per cent of magistrates and 40 nations have now had a female are women. Indeed, as the Electoral 54 per cent of school governors are Prime Minister or President in the Reform Society showed, the major - women – a common experience is last fifty years, with Hilary Clinton ity of constituencies have never that women take a next step when tantalising the world with the first elected a woman, and in fact just 291 someone actually asks them if they serious prospect of the USA joining women have ever been elected in want to take on a role, and shares the club. What better year in which to the history of the Commons. Under their own experience of doing it. put a marker down to make the 30 per cent of local councillors are The answer to engaging women is golden era of women in public life women in England, and women as much about recognising the reality become a reality?

28 Fabian Review Spring 2008 These pages are your forum and we’re open to your ideas. RD Please email Tom Hampson, Editorial Director of the Fabian EBOA Society at [email protected]. NOTIC ANNUAL HOUSE OF Fabian Women’s Network COMMONS TEA

Over 300 women turned out to hear guest speakers Tuesday 1 July 2.00, Committee Room 10 Ed Miliband MP, Boni Sones and as followed by Tea in the Members Dining Room at 4.00 the Fabian Women’s Network celebrated its three year anniversary. The Network Reception on Feb ‘Is Meritocracy Enough? 19th saw a packed room at the Jolly St Ermins The New Politics of Class’ Hotel in Westminster, with MPs including Meg Munn, Vera Baird and Fiona MacTaggart braving a Tea afterwards in the Members Dining Room. series of three line whips to join in part of the Price: £16 evening. Highlights from the evening included Boni Tickets from Deborah Stoate at the Fabian Society Sones reading extracts from her recent book Women in Parliament:The New Suffragettes Speakers include: contributing to a lively and humorous celebration of the lives of women in politics, past and present. David Lammy MP Minister for Skills, Dr Stella Creasy PPC for Walthamstow. Alan Thake (1927–2008) For further details and tickets, contact Alan was a founder member of Havering Fabian Deborah Stoate at the Fabian Society Society, which flourished due to his enthusiasm or on [email protected] and good humour. He and Eirlys, his wife, would meet speakers and provide refreshments before meetings. He was also involved with National Fabians, including acting as scrutineer. Alan was a dedicated member of the local Labour Party and expended much shoe leather EASTERN in his canvassing and leafleting. Educated at Brentwood school, Alan taught in REGIONAL secondary & primary fields and became Head of three schools. An active member of the CONFERENCE Humanists and an enthusiast for Essex Cricket, Saturday 18 October. 10.30 theatre, Bach & Jazz and especially the at the Alex Wood Labour Hall, Cambridge European Union, for which he’d served as an Education Officer. His service in Japan profoundly changed his views regards nuclear ‘The Child Poverty weapons. A recent meeting of local Fabians Challenge – the Politics with former MEP, Carole Tongue, on the 50th of Equality’ anniversary of the EU, was a fitting epitaph. Alan leaves a widow and many friends who will £10 including lunch and all refreshments. miss him deeply. Details from Deborah Stoate DAVID BALDOCK & DAVID MARSHALL.

Fabian Review Spring 2008 29 Marjorie Tait (1920–2007) Secretaries’ attempts to overspend and once, when the finances were Well known to generations of particularly dire, reporting directly to Fabians, initially as our accountant, the Treasurer that “something must be Marjorie’s background was done”. Her two-days a week in somewhat non-Fabian. Her parents Dartmouth Street were always had been tenant farmers in Sussex, accompanied by a packet of Jaffa sending her to Horsham Girls school. Cakes, which she shared round dur - From there, she joined the Civil ing an afternoon tea-break, ensuring Service, initially working for the War gossip and intelligence got passed Office in Enfield. She then on. She shared an office with the transferred to Chessington where she Local Societies’ Secretary, so felt very met Reg and settled, in 1953, into much part of the Fabian team, rather one of the happiest of marriages, first than simply a bean-counter. When in Dorking and later Betchworth. she retired from the Society, she re - After her retirement from the civil serv - turned each year as Chief Scrutineer ice, she became the Fabian keeper – from 1988 until 2003 – attending of the books – in every sense. Not each AGM to certify the results and simply writing the most orderly and renew old friendships. Her beloved precise cashbooks (so clearly set out Reg died in 1989 but, until quite re - that our auditor liked to send his jun - cently, she continued to attend meet - iors down to work on them to see ings, and to her garden, in her usual perfect double-entry book-keeping in diligent and quiet way. practice) but refusing errant General DIANNE HAYTER (FORMER GENERAL SECRETARY)

Fabian Fortune Fund Half the income from the Fabian Fortune Fund goes to support our research programme. Forms available WINNERS: Mick Cornish: £100, Giles Bridge: £100 fr o m G i le s W r i g ht, [email protected]

What should we be reading? FABIAN Advertise your latest book, pamphlet or publication on our bookshelf. For more information contact Hannah Jameson BOOKSHELF 020 7227 4911 [email protected]

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30 Fabian Review Spring 2008 FABIAN SOCIETY Join the Fabian Society

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CHISWICK & WEST LONDON [email protected] if you are 8.00 at 105 Court Lane, 29 May. Melanie Smallman of SERA. interested Dulwich SE21 8.00 in the Committee Room, Regular meetings. Chiswick Town Hall. ISLINGTON Contact Duncan Bowie at Listings 21 May. Joe Harris (General [email protected] oron June 26. Sir Nicholas Monck on the ‘Better Government Initiative’ at Secretary, National Pensioners 020 8693 2709 BATH 8.00pm in the Committee Room of Convention) on’100 Years of the Old Regular meetings – new members Chiswick Town Hall,Heathfield Age Pension’. And AGM SOUTHAMPTON AREA welcome. Terrace,London W4 4JE 25 June. Debate on Nuclear Power For details of venues and all Regular meetings at 8.00 at Islington Town Hall. meetings, contact Frank Billett Details and information from Paul Thomas on 01761 438924 email Chiswick Town Hall Contact Pat Haynes on 0207 249 on 023 8077 9536 [email protected] Details from Monty Bogard on 3679 0208 994 1780, email SOUTH TYNESIDE BIRMINGHAM [email protected] MANCHESTER For information about this Society All meetings at 7.00 in the Details from Graham Whitham on please contact Paul Freeman Birmingham and Midland Institute, CITY OF LONDON 079176 44435 email on 0191 5367 633 or at Margaret Street, Birmingham. For details contact Richard Briggs [email protected] [email protected] 30 May . Neena Gill MEP on on [email protected] and a blog at ‘Presenting a Positive Vision of http://gtrmancfabians.blogspot.com SUFFOLK Europe@ COLCHESTER Full programme of meetings 11 July. Liam Byrne MP, Minsietr of Details from John Wood on 01206 MIDDLESBOROUGH planned. State for Borders and Immigration 212100 or [email protected] New Society hoping to get For details contact Sally Cook at and Minister for the W Midlands on established. [email protected] ‘Representing the Region - a new CORNWALL Please contact Andrew Maloney on Vision of Regional Leadership’ Helston area. New Society forming. 07757 952784 or email SURREY Both at 7.00 in the Birmingham and For details contact Maria Tierney at [email protected] for Regular meetings at Guildford Midland Institute, Margaret Street [email protected] details Cathedral Education Centre Birmingham. Details from Maureen Swage on DARTFORD & GRAVESHAM NEWHAM 01252 733481 or For details and information contact Andrew Coulson 30 July. Dr Ian Gibson MP on For details of meetings, contact [email protected] on 0121 414 4966 email ‘Winning a 4th term’. 8.00 at ‘The Anita Pollack on 0208 471 1637 or 27 July. Annual Garden Party 3.00. [email protected] or Chequers’, South darenth, dartford, [email protected] Dr Howard Stoate on ‘Whither the Rosa Birch on 0121 426 4505 or Kent. NHS’ [email protected] Details from Deborah Stoate at NORFOLK Details and tickets from Maureen [email protected] New Society needs new members, Swage on 01252 733481 or Contact Tod Sullivan on [email protected] BOURNEMOUTH & DISTRICT DERBY [email protected] All meetings at The Friends Meeting Regular monthly meetings. TONBRIDGE AND TUNBRIDGE WELLS House, Wharncliffe Rd, Boscombe, Details from Rosemary Key on NORTH EAST WALES 9 May. Tom Flynn on’ Trade Unions Bournemouth at 7.30. 01332 573169 Further details from Joe Wilson on in the 21st Century’ 30 May. Sharon Carr-Brown PPC for 01978 352820 All meetings at 8.00 at 71a Bournemouth West on ‘Does the DONCASTER AND DISTRICT St Johns Rd. NHS need an Independent Board?’ New Society forming NORTHUMBRIA AREA Details from John Champneys Michael Bunney. PPC for North For details and information contact New Society forming and would like on 01892 523429 Dorset on ‘How Can We Reclaim the Kevin Rodgers on 07962 019168 new members. Electorate for Labour?’ email [email protected] For details contact Pat Hobson at TYNEMOUTH Both at 7.30 [email protected] Monthly supper meetings. EAST LOTHIAN Details from Brian Flood Contact Ian Taylor on 01202 396634  for details. Details of all meetings from Noel on 0191 258 3949 Foy on 01620 824386 email PETERBOROUGH BRIGHTON & HOVE [email protected] Meetings at 8.00 at the Ramada WATERSHED Meetings 8.00 at Friends Meeting Hotel, Thorpe Meadows, A new Local Society in the Rugby House, Ship Street, Brighton FINCHLEY Peterborough. area, details from Mike Howkins If you’re interested in joining this Details from Brian Keegan on 01733 email [email protected] or J David Details from Maire McQueeney on  01273 607910 email new Society, please contact Brian 265769, email Morgan on 07789 485621 email [email protected] Watkins on 0208 346 6922 email [email protected] [email protected] [email protected] All meetings at 7.30 at the Indian BRISTOL PORTSMOUTH Centre, Edward Street Rugby Society re-forming GLASGOW Regular monthly meetings. CV21 2EZ. Now holding regular meetings. Details from June Clarkson on For further information contact  For details contact Dave Johnson   on [email protected] Contact Martin Hutchinson on 02392 874293 email David Morgan on 01788 553277 [email protected] [email protected] email [email protected] CANTERBURY New Society forming. GLOUCESTER READING & DISTRICT WEST DURHAM Congratulations on the 50th Season For details of all meetings, The West Durham Fabian Society Please contact Ian Leslie on 01227 265570 or 07973 681 451 or of Gloucester Fabian Society Contact Tony Skuse on 0118 978 welcomes new members from all email [email protected] Regular meetings at TGWU, 1 5829 email [email protected] areas of the North East not served Pullman Court, Great Western Rd, by other Fabian Societies. It has a CARDIFF Gloucester. SHEFFIELD regular programme of speakers Details from Roy Ansley on 01452 Regular meetings on the 4th from the public, community and Details of all meetings from Steve  Tarbet on 02920 591 458 or 713094 email Thursday of the month, 7.30 at the voluntary sectors. It meets [email protected] [email protected] Quaker Meeting Room, 10 St James normally on the last Saturday of Street, Sheffield S1 alternate months at the Joiners CENTRAL LONDON HARROW Details and information from Rob Arms, Hunwick between 12.15 Regular meetings at 7.30 in the Cole Regular monthly meetings Murray on 0114 2558341or Tony and 2.00pm – light lunch Room, 11 Dartmouth Street, Details from June Solomon on Ellingham on 0114 274 5814 email £2.00 London SW1A 9BN 0208 428 2623. Fabians from other [email protected] Contact the Secretary Cllr Professor areas where there are no local Fabian Alan Townsend, 62A Low Willington, Details from Ian Leslie on 01227 265570 or Societies are very welcome to join us. SHROPSHIRE Crook, Durham DL15 OBG, 07973 681451 New Society forming needs tel, 01388 746479 email HAVERING enthusiastic new members. [email protected] CHELMSFORD AND MID ESSEX Details of all meetings from David Contact Bob O’Brien on 07970 New Society forming, for details of Marshall email 850196 email [email protected] WEST WALES membership and future events [email protected] Regular meetings at Swansea SOUTH EAST LONDON Guildhall Please contact Barrie Wickerson on 01277 824452 email HERTFORDSHIRE Meet at 8.00 at 105 Court Lane, Details from Roger Warren Evans [email protected] Regular meetings. Dulwich London SE21 7EE on [email protected] Details from Robin Cherney at For details of all future meetings, CHESHIRE [email protected] please visit our website at WIMBLEDON New Society forming in http://mysite.wanadoo- New Society forming. Northwich area. HUDDERSFIELD AREA members.co.uk/selfs/ Please contact Andy Ray New Society forming. 9 April. Ellie Levenson on ‘Feminism on 07944 454161 if you are Contact Mandy Griffiths on [email protected] Contact Jo Coles at in the 21st Century. interested

32 Fabian Review Spring 2008