Some thoughts on Rethink: build back fairer

Fairness, actually, is all around it seems this year. I know that my RAS (reticular activating system) is particularly alert to the term, but it isn’t just that: it’s clear that the Covid-19 crisis has brought many to the conclusion that fairness matters, and that focusing on fairness is more worthwhile than on the narrower numerical concern of inequality.

A key example is the apparent rebranding of the Rethink series on Radio 4 – which started with the Pope’s comments on poverty – to be Rethink Fairness. As host Amol Rajan explained, fairness was a term that just kept on coming up in the Rethink commentaries. This led to a series of five special discussions over last week, considering Rethink Fairness on: wealth, regions, education, health and generations.

The most striking part of the series was that both the education and health discussions focused less on disparities in education and health outcomes in themselves, and much more on those disparities as symptoms of broader unfairness in society. In each case, the suggested responses seemed more to do with addressing poverty and a lack of opportunity, particularly in some regions of the country, than with issues in education and health specifically. Both the health and education systems, it was noted, are too often asked to backfill for other failings.

Typical was this exhortation from the excellent Sammy Wright, vice principal of Southmoor Academy in Sunderland, and a member of Social Mobility Commission:

“We have to support people outside school, we have to have an adequate welfare safety net, we have to have services and we have to have people who can provide that whole wrap-around culture for struggling families.”

Similarly, “Good health is not about the health service, the health service is sorting that out when it’s gone wrong,” said the wonderful Dame Julie Moore, former nurse and recently retired chief executive of University Hospitals Birmingham NHS Foundation Trust. “The health service ends up sometimes picking up the price for the basic inequality in income, in housing, in circumstances.” She went further: “Sometimes the health service is there to fulfil a need that should not have arisen; we can’t expect the health service to solve all these problems.”

“Most of the difference that we see between children can actually be explained by their family background, their family income, factors outside of their school,” agreed Anna Vignoles, professor of education at the University of Cambridge. “It’s not surprising when you think about the influence of families and the amount of resource that they have, that they are making more of a difference than schools.”

Professor Sir Michael Marmot identified four mechanisms that in his view link our poor health pre-pandemic with our poor health during the pandemic. These four mechanisms are explored in detail in Build Back Fairer, last month’s report he co-authored on lessons to be learned from Covid-19 and reflecting on his decade of recommendations to the government for reform. Again, these are issues that go much broader than health as such:

  1. Quality of governance and political culture 
  2. Widening social and economic inequalities
  3. Investment in public services
  4. Health had stopped improving prior to the pandemic, which increased the risk of lethality during the pandemic

Vignoles put the call for action in similarly broad terms: “What we’re really facing pre-Covid, post-Covid, during Covid, is economic inequality in our society that also is mirrored in our education system and so if we’re serious about changing that we do have to work on the economic inequality that sits outside of schools first, or at least at the same time, because without tackling that we’re always going to face a problem in our education system.”

Furthermore though, it was clear that, just as many of the problems faced by the health and education systems arise from broader societal fairness issues, it is also true that addressing some of the health and education challenges – and investing more smartly in them – gives an opportunity to address future unfairness and create a nation in which we would all prefer to live. Getting these issues right can help with society as a whole, not just education and health in themselves. With so much focus on infrastructure spending, a key question is what infrastructure will actually matter for the future we want. There was some cynicism as to whether this should be physical transport links, and the suggestion that rather, it should be something smarter to suit the 21st century.

At its heart was a call not to see infrastructure just as concrete and steel. “View health as an investment in the nation’s infrastructure,” said Moore. “It’s a necessary part of our infrastructure, and it’s a really valuable investment on every front.”

Actually, the clearest articulation of the need for skills and investment in people and fairness rather than hard infrastructure came in the programme on Regions: “It’s not about faster trains between cities in the North of England, which would be used by richer people, it’s about trying to give people further down the ladder the skills that they need to get on in the world of work, and then also make that place a more attractive place to come and do business as well,” explained Paul Swinney, director of policy and research for the Centre for Cities.

This argument for a heavy investment in skills and training – and scope for retraining for those whose former jobs are no longer as valued – becomes more powerful when one considers the arguments of Harvard Professor Robert Putnam, of Bowling Alone fame. Putnam suggests that the rise of American public schooling in the progressive era (the years around 1900), which essentially provided a basic education for the entire population for the first time, readied the skills of its people and helped pump-prime the economy, providing the foundation for the economic success of the American century. 

If we aim to have a successful next century, we need to prepare our young people to succeed in it.

There were six areas of recommendations in the original Marmot Review, Fair Society, Healthy Lives, which again go far beyond a narrow understanding of health. They are a good basic set of ambitions for a nation to set itself:

  • Give every child the best start in life.
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives.
  • Create fair employment and good work for all.
  • Ensure a healthy standard of living for all.
  • Create and develop healthy and sustainable places and communities.
  • Strengthen the role and impact of ill health prevention.

There seems no better message on which to end.

Rethink Fairness, Radio 4

Social Mobility Commission

Build Back Fairer: The Covid-19 Marmot Review, Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Herd, Joana Morrison. The Health Foundation, December 2020

The Marmot review 2020 – the government must go further. Royal College of Physicians, February 2020

Health Equity in England: The Marmot Review 10 Years On, Michael Marmot, Jessica Allen, Tammy Boyce, Peter Goldblatt, Joana Morrison. Institute of Health Equity, February 2020

Fair Society, Healthy Lives, Michael Marmot, Jessica Allen, Peter Goldblatt, Tammy Boyce, Di McNeish, Mike Grady, Ilaria Geddes. Department of Health, February 2010