At a meeting in Plaid Cymru’s conference in Cardiff Holtham disarmingly pulled apart many of the assumptions of his hosts.  Every time Helen Mary Jones or Dafydd Wigley lit a flame of hope, Holtham gently placed his fingers on the wick and extinguished it.

A fair share for Wales?  You’ll be lucky.  Though Wales is £300m under-funded by his calculations the Treasury say that’s within the margin of error and would quickly disappear with a different set of assumptions.  But the real problem is that using the same calulation Scotland gets £4.2bn-a-year more than it would if every part of the UK was treated the same as an English region.  With the SNP running strong the Treasury won’t consider change: ”If you think they’re going to change that, forget it” (quotes courtesy of Tom Bodden).

A fairer income tax regime in Wales?  Not on your nelly. The high earners would flee across the border: ”You would get virtually no revenue from the upper rate of income tax and if you raise it too far you would probably lose it…If you want to maximise revenue you would cut the upper rate of income tax, [and] put a penny on basic rate…How you explain that to the Welsh electorate I don’t know.”

How about a tax on natural resources then?  Small change.  Even if you could overcome the barriers a tax on water exported from Wales would only raise about £30 Million a year – and the Treasury would probably deduct it from the Welsh block in any event.   Not worth the grief.

But Helen Mary Jones refused to be sidetracked, this simply confirms that Wales needs to flex our muscles more she said.  The Scots have shown that extra support for the SNP gives the country greater leverage (though Plaid’s affection for the SNP may not last long if there’s a hung Parliament.  Dafydd Wigley said they’d be working at cross purposes and should hold separate negotiations with the Tories).

Helen Mary went on to say that the Conservatives might not mind “annoying the voters of Scotland” because they have so few votes there.  But I don’t buy that.  My reading of the Conservatives is that they see the generous Barnett settlement for Scotland as a price worth paying for keeping the Union together.

But Gerald Holtham did give leave his audience with some cause for hope. The Calman Commission in Scotland suggested extending the tax-raising powers on the grounds of accountability.  Without a stake in revenue raising the Executive will have too easy an excuse to blame London for not providing sufficient funds.  The UK Treasury have accepted his argument.  “That’s boxed me in” Holtham explained.  ‘How can I not recommend tax raising powers now’ he mused…

The Report talks about ‘positive attachment between a young child and the care giver’:

“Early, secure attachments contribute to the growth of a broad range of competencies, including the self esteem, self-efficacy and positive social skills that are associated with better educational, social and labour market outcomes in later life.”

In his BBC News interview Professor Marmot was more direct about what this actually meant:

Every child needs to be nurtured at an early stage.
“In one study, mothers were asked whether it was important to cuddle and talk to a child.
“I would have thought every mother would have said yes to that – but not all of them did.
“That made my hair stand on end.
“And it follows the social gradient – women from less well-off families are less likely to see this as important.
“But then by the age of three, these children had more behavioural problems and worse cognitive skills.
“Then they have less readiness to learn, and the problems continue.”

We know from research on Romanian orphans that by the age of three neglected children have irreversible brain damage on MRI scans. This fits with my experience as a Valleys general practitioner although the picture is much more complex: whilst it is common to find infants and toddlers strapped in pushchairs and baby seats on a home visit at some addresses, it is rare to find emotionally cold, show home-tidy and socially isolated homes in those streets.

Over the years I have got very angry with commentators who have told me that the answer to Merthyr’s problems is to make everyone middle class with middle class values. I have also been rebuked by Health Visitors and Social Workers when I have used sitting with an infant and reading as a measure of good parenting. How do those of us concerned with addressing these complex challenges bring about change sensitively and effectively and break the generational cycle of inadequately cwtched infants?

But what’s happening to the poorest is only part of the story. The other part is what has happened to the incomes of the rest of society – because poverty is defined in relation to social norms.  And here is the rub: over the last 10 years the incomes of vast majority of households – the middle 80% – have gone up by around 25% (those on lower incomes have done slightly better). But the poorest 10% have seen a fall in real incomes over the decade, whilst the richest 10% have seen their incomes rocket by almost 40% (see http://www.poverty.org.uk/09/index.shtml).

There will be no eradication of child poverty while society polarises in this way. Ending child poverty needs some unpalatable action to close the income gap – increasing benefits for the very poorest and increasing taxes at the very top.  Without action to redistribute income, all the other much needed action is doomed to fail.

Interestingly, they found that even when all these risk factors were accounted for, individuals from the most deprived areas had around a 1.5-fold to 2-fold higher risk of plaque presence than those from least deprived areas.

The authors concluded: Health status is a reflection not only of features of the individual but also of wider social and economic influences, health and social services, early life experiences, and environmental factors. These findings fit in with the work of Marmot and Wilkinson who have been studying these issues for more than twenty years. Blaxter, reported in the Health and Lifestyle Survey, a large research study published in 1990, that only wealthy people could improve their health by changing their lifestyles. Indeed, she also showed that poor women who smoked enjoyed better health than poor women who did not smoke; a message that the Health Promotion industry has chosen to ignore.

I came to Merthyr as a general practitioner inspired by Julian Tudor Hart to “walk one mile up the river” in order to help people not to fall into the rivers of disease, disability and death. There are many changes that I can help individuals to make to reduce the risks of bad things happening to them, but the real health and well being dangers that my patients face have much more to do with inequality and inequity.

Will the new leader of Welsh Labour have the ideas and the policies to tackle these challenges and make a real difference to our health statistics?