The Lancet, Volume 376, Issue 9753, Page 1617, 13 November 2010 Original Text
The Lancet remembers well the genuine excitement we felt at the commitment that the Labour government made in 1997 to attack health inequalities in Britain. The dismal record of the Conservatives before them—who hated the very idea of inequalities, preferring instead “variations” in health—left a deep scar on the National Health Service. The creation of Donald Acheson's Independent Inquiry into Inequalities in Health was a new opportunity to recalibrate the health service to meet the needs of the most deprived communities in the UK. Our sense of hope was, it turned out, misplaced. Labour presided over 13 years of failure. Inequalities in health widened despite huge investment in the NHS. The reasons for this failure have now been exposed in an astonishingly candid report, published last week by the House of Commons Public Accounts Committee. This committee examines how taxpayers' money is spent. It is chaired by a Labour Member of Parliament, Margaret Hodge. She has produced a tale of decrepitude at every level of the health system.
Labour was elected in 1997 with a promise and mandate to tackle inequalities in health. Yet it took 9 years (to 2006) before ministers and their civil servant officials made inequalities an NHS priority. “What on earth went wrong?”, asked Hodge. She was questioning the Department of Health's Permanent Secretary, Richard Douglas, together with Ruth Hussey (a regional director of public health) and Mark Davies (the Department's Director of Health Inequalities). Douglas was evasive. Hodge dismissed his “claptrap” as “despairing”. Eventually, he admitted that his Department's interpretation of ministers' election commitments was merely “aspirational” (ie, it did not have to be taken seriously).
The picture of government he painted was far from flattering. Figures showing the worsening situation for health equality would be sent to the Department and forwarded to ministers. But civil servants—including, it seems, the Chief Medical Officer—did little to address the growing problem. The best officials could do collectively was send out “toolkits” of guidance to primary care trusts and cross their fingers that they might trigger a response. But the Department had no mechanism to monitor or evaluate the implementation of what limited guidance it did provide. It was a “fair criticism” to say that “we were slow off the mark”, conceded Douglas. Members of the Public Accounts Committee were clearly shocked by this admission. As Hodge put it: “It takes us nine years—that is just gobsmacking.” Another said, “it's a mess, it's a tragedy really.”
The government and civil service were not wholly to blame. Where was the medical profession? Doctors are supposed to feel an acute responsibility to deliver the best health service to the whole population. It is on this basis that they ask the public and government to support generous pay increases and terms and conditions of service. These attitudes and behaviours are what we commonly mean by professionalism. It seems that doctors failed completely to live up to the rhetoric of their commitment to professional values. Members of Hodge's committee tried to find out why doctors had been so reluctant to address inequalities themselves. There are some simple and proven interventions that, if implemented evenly across the population, would go a long way to reduce inequalities in health—notably, smoking cessation and the treatment of high blood pressure and raised cholesterol. But doctors did not respond to the clear public and political call to take action on inequalities (and nor did the media). Instead, they sought to massively increase their salaries in a new general practitioner (GP) contract in 2005, one that itself was empty of commitment to reduce inequalities. People died because of this professional failure. The negotiators of that GP contract, together with the Department of Health, share a responsibility for those deaths.
During the course of this systemic failure, the Department of Health employed over 2300 people. Mr Douglas earns £170 000. Yet this great number of civil servants and their highly paid Permanent Secretary (including Mr Douglas's predecessors) failed to deliver on a public promise, democratically endorsed. A bureaucracy's first priority is usually to protect itself. Only secondarily will it try to deliver on the pledges of its political leaders. To call this period in the Department's history shameful does not even begin to do justice to the way it let down the millions of people to whom it owed a duty to serve. Despite the bland reassurances made to the Public Accounts Committee, there is not one shred of evidence that the Department has learned the lessons of this agonising debacle.