Johnson keeps the faith on inequalities

Alan Johnson has made tackling health inequalities one of his priorities as secretary of state. In his first major speech in the job, he promised to focus on breaking the links between lack of wealth and poor health.

In a year in many ways dominated by Lord Darzi's next stage review of the NHS, Mr Johnson's persistence in returning to his theme has meant that not only does everyone in the NHS know by heart his oft-quoted example that life expectancy decreases by one year for every stop from Westminster to Canning Town on the Jubilee Line, but it is a fair bet that a reasonable number of the general public do too.

With the Conservatives promising to set up a Department of Public Health distinct from the NHS, Mr Johnson has fought to ensure Labour gets what he sees as its due credit for prioritising health inequalities.

Despite the stark statistics, Mr Johnson does not want people to feel the problem is too depressing. "It is a challenging agenda, but I don't think there's any need for a counsel of despair," he tells HSJ. "If you think back to the history of this, we lost 18 years virtually [while the Conservatives were in power]. It's not a political point, it's a fact."

Since 1997, however, he claims things have changed dramatically. The health secretary is confident the 2010 target to reduce health inequalities and life expectancy at birth by 10 per cent will be met.

But he stresses the gap has become harder to close because everyone's health has improved. "We're not here to say our one aim is to improve the health of the poor and we don't care about everyone else. But if the health of the middle classes and the upper classes and all the rest hadn't improved, it wouldn't have just been a closure of 10 per cent, the gap would have gone completely over eight years," he says.

He is also confident that the phenomenon of there being twice as many GPs in leafy suburbs as in inner cities, "a blight on the NHS for 60 years that's never been tackled", is about to be brought to an end.

There are 113 new GP practices being built - in addition to the new GP-led health centres - in the 20 per cent of primary care trusts with the lowest number of family doctors per head. Once they open, "that's the end of under-doctored areas", he claims.

Jargon with purpose

Mr Johnson is clear that everyone - young or old - is entitled to the same treatment. Asked his view on whether younger people should be given greater priority when allocating resources than older people who have had their "fair innings" he is unequivocal.

Age discrimination must not be tolerated, he says. "I don't believe in the 'fair innings' argument at all, if the fair innings argument means they've had their innings, it's time for them to go quietly to the pavilion at sunset and drift away. That's just not what the NHS is about."

He knows the world class commissioning mantra "adding years to life and life to years" is jargon, but "it's jargon with a purpose".

"There's absolutely no reason now that people should be feeling at age 60 that it's time to curl up and wait for Godot."

And, while he is not prepared to talk about the review of co-payments, he is clear it is not about people having different entitlements. National cancer director Mike Richards is looking at whether the definitions of "episodes of care" are still relevant, for example. "His terms of reference make no mention of fair innings," Mr Johnson laughs.

He would like to see people in deprived communities becoming more assertive about their health needs. His generation - "I'm a baby boomer as well" - will change the system as they pass through it, he says, and everyone should get an equal say. "You want the people in disadvantaged areas who basically were so pleased that there was an NHS that they're still kind of happy to queue and be grateful for what they get, for them to have the same assertiveness."

And, while there is much to be done, he is not criticising GPs for not doing enough. "There's no argument between us and the BMA on this. They are determined to tackle health inequalities." The minimum practice income guarantee has been a "pernicious factor", he adds, but as it is phased out, health inequalities will shrink.

Neither does he chastise PCTs, despite poor ratings for quality of services in the most recent annual health check. They're probably not at a consistent standard on inequalities, but he's "not casting any aspersions" on them. He says "it takes a while to get settled down" after reorganisations, and some time to get used to the huge increase in the money available. Similarly, they "could probably do better" at leadership, and may not have the right mix of skills on their boards, but "it's not my number one concern".

Co-ordinated action

The health secretary is extremely positive about his local constituency PCT in Hull - "brilliant" - and repeatedly praises what spearhead PCTs have done. He only diverts from his PCT praise when it comes to London, saying that although he won't impose any changes, having 31 PCTs "doesn't strike me as being the most sensible arrangement".

He stresses the need for joint working; and co-ordinated action. "Sure Start is as important a policy on tackling health inequalities as anything we're doing in health, the New Deal to get people back into work, what they are doing in housing to ensure there are better standards in housing and more housing available, what we're doing on literacy and numeracy." With his background as education and work and pensions secretaries, he's particularly well placed to ensure these initiatives meet in the middle.

PCTs must get involved too, he says, "recognising that their job is actually to be in there with the local strategic partnerships looking at housing and unemployment and trying to tackle all these problems."

Asked how, amid the economic crisis, he will ensure inequalities and public health are not the first to suffer, he says the operating framework will keep things in place.

"I think [NHS chief executive] David Nicholson is doing a brilliant job in the NHS and he's one of the real attributes we've got. His message to say, look, it's inconceivable that the next spending review will see as big a growth as we've seen in the past and you need to have a fix on the next five years rather than just the next two, I think that's important. And every penny we spend in the public sector will have to be remorselessly examined to make sure it's getting good value for money for taxpayers."

Mr Johnson is looking ahead. The DH has commissioned epidemiologist Sir Michael Marmot to consider what the government should focus on after 2010.

Of course he cannot make spending pledges beyond the current settlement, but he can keep the political commitment alive. "As long as we're in government, given the history of this issue, tackling health inequalities will be a priority."

More on health inequalities

Health inequalities: wealthiest overfunded as the poor lose out

Health inequalities could be forgotten as cash gets tight

PCTs say realpolitik is behind unequal healthcare

Hold your nerve - equality is not an expensive indulgence

Michael Marmot on eliminating social injustice in health

Welfare reform will overcome health inequalities

NHS rationing: the time of their lives