A year after the Acheson report on health inequalities - which won enthusiastic backing from the government - is the UK any nearer meeting its objectives? Wendy Moore reports

Inquiries into health inequalities have a habit of provoking strong reactions from governments - usually in their efforts to muzzle the findings.

Edwin Chadwick had to publish his 1842 Report on the Sanitary Condition of the Labouring Population himself after the Poor Law Commission refused. The last Conservative government attempted to stifle the 1980 Black report on inequalities and abolished the Health Education Council, allegedly in revenge for publicising The Health Divide in 1988.

The response to the report of Sir Donald Acheson's inquiry, Inequalities in Health , which reaches its first birthday tomorrow, has been equally forthright. But this time the government has fallen over itself to offer pledges and plans on a range of fronts - including benefits, housing, food, smoking, children and employment - highlighted by Acheson's 39 recommendations. The question is: will it make any difference?

Public health analysts suggest that success has so far been mixed - applauding radical moves like increases in child benefit, rising employment, the national minimum wage and higher pensions designed to help the poorest in society, but ultimately doubtful that the health divide is closing.

'From the last figures I saw people have speculated that it might have worsened, ' says Geof Rayner, chair of the UK Public Health Alliance.

The likeliest reason, he argues, is that while government has rightly targeted action at lifting people out of poverty, it has done little at the other end of the scale - to curb excesses of wealth.

While absolute poverty may fall, relative poverty could increase and this, many public health experts believe, is the main cause of health inequality.

Department of Social Security statistics covering Labour's first year in office show that the average income rose by up to 8 per cent from 1994-95 to 1997-98, but income for the poorest 20 per cent went up by 3 per cent or less.

The figures published last month reveal that in 1997-98, 24 per cent of people received less than half the average income (after housing costs) - a measure generally taken as an unofficial poverty line - which is a rise since the 1995 figures cited in the Acheson report. The picture is tentatively confirmed by other figures.

The New Earnings Survey 1999, issued by the Office for National Statistics last month, shows that average weekly earnings rose by 3.7 per cent between April 1997 and April 1998, yet non-manual workers' pay went up by 1.2 per cent more than that of manual workers.

In contrast, however, the figures also show that between 1998 and 1999, earnings of the bottom 10 per cent rose faster than those of the top 10 per cent (4.3 per cent compared with 3.7 per cent).

Meanwhile, the north-south divide continues, according to a survey of household income by market research group CACI. People in Sunderland are 32 per cent poorer than the national average and 88 per cent worse off than families in west London, its 1999 study, also out last month, shows.

There are as yet no figures showing the direction of health inequalities since 1997, but experts are not optimistic.

Sir Donald himself declined to give his views on the government's response to his '39 steps', although it is understood that he is monitoring progress. None of the other five members of the inquiry were available for comment.

But Dr Catherine Law, former scientific secretary to the inquiry and senior research fellow at the Medical Research Council's environmental epidemiology unit at Southampton University, agreed to speak in a personal capacity.

She describes the increases in child benefit and other benefits for poorer families as 'very welcome', and says community-based, multi-sectoral initiatives like Sure Start - enabling communities to improve their own health - are 'exactly the sorts of things we were trying to recommend'.

The government itself has lost no opportunity to publicise its efforts since Acheson, although its official response, overshadowed when it came out the same day as the public health white paper in July, mainly reiterated moves already in place.

More significantly, the 1999 Budget included several measures to reduce inequality, including a second increase in child benefit due next April and the children's tax credit for families with children (except for high earners) due in April 2001. Pensioners won a£100 winter fuel bonus (a fivefold increase) and a pension rise from next spring.

This was followed in September by the government's poverty strategy which pledged to end child poverty within 20 years. Chancellor Gordon Brown's pre-Budget speech earlier this month added the promise to halve child poverty within 10 years.

Together, the government claims, these measures will provide£6bn in extra benefits to lift 1.25 million people, including 800,000 children, out of poverty by the end of this parliament.

'Quite a lot has happened, ' says Bharti Patel, director of the Low Pay Unit. 'But we won't see the results of these improvements, especially in child poverty, for a while yet.'

Already, however, the national minimum wage introduced in April has seen women's pay rise by as much as 12 per cent, she says.

Paul Ennals, chief executive of the National Children's Bureau, agrees that the government has made a 'reasonably promising start'.

But raising benefits is not enough, he warns. He points out the logical - but not always obvious - point that eradicating childhood poverty in two decades means changing the lives of the children of today's children.

Raising self-esteem, supporting families before a crisis occurs and providing emotional help will be as important as providing jobs, he argues.

Anna Coote, public health programme director at the King's Fund, awards the Treasury 10 out of 10 for its efforts. Moves to raise income for low earners and increased child benefits should have a significant long-term effect on health. But if next year's Budget cuts tax to all earners, as promised, that would 'obviously increase inequalities'.

On the ground, Acheson has clearly prompted action, but whether this will stem inequalities remains unclear. In Liverpool, which emerges as Britain's poorest area in the CACI income survey, communities have welcomed the recognition of issues being raised for years, says Liverpool health authority's public health director, Dr Ruth Hussey.

'Anything that we can do to start to increase income levels in the city will have a direct benefit on health, ' she says.

One local project has already shown that increasing take-up of benefits directly improves health. Others are concentrated on enabling local people to define their own solutions.

But she fears other areas may still move ahead faster and widen inequalities yet further. Liverpool's death rates declined more slowly than elsewhere between 1994 and 1997.

Dr Hussey says: 'We need to find ways of moving together across the country at the same pace.'

What happened next: Acheson and after

The Acheson report made 39 recommendations, including calls for action on poverty, housing, education, food, water, transport, pensions, childcare and smoking. Reducing income inequality and helping families with children were designated priorities.

Steps forward Action by the government includes increased child benefit, increased pensions, children's tax credit for families with children, pensioners'£100 winter fuel bonus,£200 Sure Start maternity grants, above-inflation increase in cigarette prices, one week's nicotine patches on prescription to help poorer smokers give up, national minimum wage, review of water fluoridation and reduced unemployment.

Steps back Top wages still rising, tax cuts promised for next year, alcohol duty frozen, disability benefits threatened.

Standing still Action still awaited on public transport investment, curbs on cars, free fruit in schools.