Editorials

Policies to tackle social exclusion

Must deal with the iceberg and not just its tip: this is an issue for all society

Papers pp 187-209 Primary care pp 210-7

In the past 20 years the United Kingdom has become a more unequal society in which many people have prospered while many others have not. ^{1 2} This issue includes several examples of the adverse health and social effects for groups that have been excluded from general prosperity (and some attempts to ameliorate these effects). But the consequences of social exclusion provide too narrow a focus. Society as whole is also affected and needs to be engaged in supporting solutions to the problem.

Differences in life expectancy between socioeconomic groups have widened, mainly as a result of faster rates of improvement in affluent groups. ^{1 3} Socially patterned premature mortality is the most stark form of social exclusion, but it occurs late in the process, usually after several decades of living in adversity. ^{4 5} It is not known to what extent this pattern is being repeated in later generations, whose early life circumstances have been generally more favourable. Nevertheless, the proportion of children born and brought up in households with less than half of average income tripled during the 1980s, catapulting the UK to the highest rates of any country in the European Union. ^{6 7} This generation is now reaching school leaving age. We have still to learn the consequences of living in a society in which nearly a third of adults have been brought up in conditions of relative poverty, though the US may be a guide.

The early correlates and consequences of child poverty for children and young adults include adverse trends in reading skills, unmanageable and aggressive behaviour at school, drug misuse, unemployment, teenage pregnancy, homelessness, crime, and suicide.⁸ These are the symptoms and signs of social exclusion, which has been defined as "the inability of our society to keep all groups and individuals within reach of what we expect as a society and the tendency to push vulnerable and difficult individuals into the least popular places."⁹

The government is committed to addressing these problems and has launched many projects to tackle social exclusion in its many forms.¹⁰ In most cases it is too early to judge the effectiveness of such initiatives, whether they provide value for money, and whether it is feasible or affordable to extend them beyond the initial sites. It is possible, however, to question whether this approach represents an adequate response to the processes of social exclusion. Many initiatives come late in the process, addressing consequences rather than causes. Their targeted nature is also limiting.

Geoffrey Rose criticised the tendency to view marginal groups as "problem groups, different and separate from the rest of their society."¹¹ He likened such problems to icebergs whose visible tips can neither be understood nor properly controlled if they are thought to constitute the entire problem. Rose argued that a population strategy to sink the iceberg rather than to attack its tip is necessary whenever risk is widely diffused throughout the whole population.

The government's commitment to education embodies this broader approach, seeking to ensure that children are ready for, motivated by, and prosper as a result of the educational system. The policy is complemented by the Sure Start programme, and its Scottish equivalent, Starting Well. These aim to replicate in the UK the experience of projects in the US that show how intensive home support for poor families in the preschool period can result in educational and social benefits for individual families, local economies, and society as a whole.¹²

Policies to address the problems of target groups are welcome, if they work, but essentially provide micro solutions for a macro problem. The inverse relation between school performance and socioeconomic circumstances is not confined to a minority of problem schools and areas but is a continuous relation that is observed across society.¹³ Targeting misses large numbers just above the arbitrary threshold. Sinking the iceberg, rather than attacking its tip, is a better basis for public policy.

The government has sworn to eliminate child poverty within a generation and is spending large sums on education. It is too early to assess achievements, but the likely impact of these policies seems constrained by a determination to limit public spending as a proportion of gross domestic product. Opposition parties in the recent UK general election were hardly more daring, their policy differences being contained with a ±1% margin of gross domestic product.¹⁴ None of these policies seems adequate to address the scale of the choices we face. The diagnosis and treatment may be correct, but the prescribed dose is wrong.

The low turn out at the recent election has been attributed to the disillusionment and disengagement of many groups. The worrying corollary is that the outcome of elections is now determined by the voting habits of a relatively affluent minority, concentrated in marginal constituencieswho are socially excluded in a different way. As Hutton argues, "The top 10% can buy themselves such high quality private education and health care that they cease to have an interest in the education and health the state provides; they resent the taxes they have to pay for services they will not use. One of the underpinnings of the welfare statethat it is perceived as a structure for everyoneis thus eroded; it becomes a second best system from which the better-off escape. The boldness which allows them to argue that this escape is a moral obligation for them and the poor, helps legitimise their self-interest."¹⁵

The UK remains a relatively lowly taxed country compared with its European partners.⁷ In the US public spending as a share of national income is about 30%, in the UK about 40%, and in continental Europe often around 50%. We cannot have European levels of service with UK levels of tax, or American levels of tax and British levels of service.¹⁴

The solution to social exclusion lies not in myriad attempts to repair society at points of breakdown, but in persuading relatively affluent groups that social inclusion is worth paying for.¹⁶ Ironically, it was a US Chief Justice, Oliver Wendell Holmes, who said, "Taxes are the price we pay for a civilised society." As recession looms, and the government has less scope to redistribute by stealth, this is the issue to which UK society must return.

Graham Watt, professor of general practice. 

Department of General Practice, University of Glasgow, Glasgow G12 0RR (G.C.M.Watt{at}clinmed.gla.ac.uk)