What did the government promise?
In 1997, a boy born into the poorest social group was likely to die nine years before a boy born in the richest social group. In addition to inequalities in life expectancy between social and economic groups, the data pointed to health inequalities between the north and south of the United Kingdom, and between different ethnic groups.
The Labour government has responded with a range of initiatives. In 1997, it commissioned former Chief Medical Officer, Sir Donald Acheson, to carry out an independent inquiry that found widespread evidence of health inequalities, and recommended action in the NHS, and on poverty, housing, transport, education and employment.
In 1999, its White Paper, Saving Lives: Our healthier nation, focused on setting national targets to combat particular diseases, and charged local health authorities with the task of developing local health improvement plans.
In 2001, national targets to reduce health inequalities were set, followed by a two-year interdepartmental review. The government’s 2003 report, Tackling Health Inequalities: A Programme of Action, supported existing initiatives designed to improve health and reduce the health gap. These included targeted action in the areas of education; welfare-to-work programmes; environment, housing and urban regeneration initiatives; and better transport.
Most recently, its 2004 White Paper,
Choosing Health: Making healthier choices easier, published after an extensive consultation process, places a strong emphasis on the importance of personal choice and changing individual lifestyles and behaviour to ensure better population health, with a special focus on disadvantaged communities.
What has its strategy been?
Income inequality in the UK rose by five per cent between 1996/97 and 2002/03, with the richest one per cent of the population holding a greater total annual income than the bottom 30 per cent.
New Labour's strategy has been to focus on primarily targeted poverty-reduction programmes, rather than measures to tackle income inequality more widely. From 1997 onwards, it has maintained a steady flow of initiatives aimed at reducing people's dependence on welfare benefits and increasing numbers of people in work.
It has also pledged to end child poverty within 20 years, and set itself challenging targets for reducing the gap between the health of better-off and poorest groups in society.
What has it done?
Fiscal measures have included setting and enforcing a minimum wage; establishing tax credits, which in effect operate as more generous benefits for working families with children.
Community-based interventions have included substantial investment in an ambitious range of programmes intended to improve health and well-being in disadvantaged communities through action on regeneration, employment, education, housing and crime.
Between 1999 and 2004, for example, the government spent £1.3 billion on 500 Sure Start programmes, designed to improve the health and well-being of very young children and their families.
Launched in 1998, its £1.9 million New Deal for Communities targets unemployed people, disadvantaged communities, lone parents and disabled people in some of the most deprived neighbourhoods in the country.
Twenty-six Health Action Zone programmes were established, with a budget of £449 million, to improve the health of some 13 million people in deprived areas.
Healthy Living Centres, with a budget of £300 million, aim to tackle local inequalities and involve local communities in improving their own health.
Local Strategic Partnerships, introduced in 2001, are the government’s main vehicle for co-ordinating interventions by different agencies in deprived areas. These were initially established with 88 local authority areas, and received Neighbourhood Renewal Funds amounting to just over £2 billion from 2001 to 2006.
These programmes have not been fully evaluated as yet. Health Actions Zone programmes have now been brought to a close, but an evaluation concluded that it was too early to judge their effectiveness.
Have differences in income reduced?
In terms of income inequalities, in the five years from 1996 to 1997, the numbers of people living in poverty in the UK dropped from 13.9 million to 12.4 million.
Pensioners and children have benefited most. But this needs to be balanced against the fact that almost four in ten people without children are now below the poverty line (that is, existing on less than half the national average income) – a slightly higher rate than when Labour came to power in 1997.
What has been achieved?
In 2001, the government pledged to reduce inequalities in health outcomes by 10 per cent by 2010, as measured by infant mortality and life expectancy at birth.
Average life expectancy in the UK has improved, but the gap between average life expectancy in England and that in the lowest fifth of local authorities increased between 1997 and 2003 by two per cent for males and five per cent for females.
The infant mortality rate for the population as a whole also fell between 1997 and 2003, but the latest data for 2001/03 shows that the gap between the most and the least well-off groups has widened.
In 2004, the government added an inequalities dimension to the national targets it set in 1999. By 2010, it hopes to have reduced the inequalities gap in mortality rates for heart disease and stroke between the fifth of areas with the worst health and deprivation indicators and the population as a whole by 40 per cent, and the gap for cancer by six per cent. Data is not yet available to assess progress.
National mortality rates for cancer, heart disease and stroke have declined. But the end of the last decade, premature death rate for heart disease for male manual workers in England and Wales remained 58 per cent higher than that of male non-manual workers.
Socio-economic inequalities also still exist for suicide. In 2002, men aged 15 to 20 in routine and semi-routine occupations were three times as likely to commit suicide as those in professional and managerial occupations.
What challenges still exist?
By 2010, the government wants to reduce the conception rates among teenagers (women aged under 18) by half. Between 1998 and 2003, under-18 conceptions fell by 10 per cent and under-16 conceptions by 12 per cent. Most teenage births are in the manual classes, and the rate is still higher than elsewhere in Western Europe.
It also wants to reduce obesity rates among children. But between 1995 and 2002, boys and girls classed as overweight or obese increased by 27 per cent and 21 per cent respectively, with more obese or overweight children among manual classes. Adult obesity is also increasing.
Thirty per cent of women in the poorest fifth of households are obese compared to 17 per cent in the richest fifth. There is little difference for men.
The government plans to reduce smoking prevalence in routine and manual socio-economic groups from 31 per cent in 2002, to 26 per cent or less by 2010. People in these groups are nearly twice as likely to smoke as people in managerial and professional classes, and this accounts for a great deal of the difference in life expectancy between social groups.
The evidence suggests that there has been no narrowing of the inequality gap, though recent evaluations of the government's smoking cessation programme suggest that it does reach smokers in the most disadvantaged areas.
How equal is access to health services?
Communities in greatest need are least likely to receive the health services that they require, and this situation still applies in many parts of the country.
Unequal access to services is not restricted to social class and geography. People in some minority ethnic communities are less likely to receive the services they need. Many deprived communities are also less likely than affluent ones to receive heart surgery, hip replacements and other services such as screening.
The government's Performance Assessment Framework for the NHS now includes ensuring 'fair access' to health services according to need as one of its goals. The government’s health care watchdog, the Healthcare Commission, will incorporate measures of inequalities in health and access to health care as part of its annual assessment of NHS organisations.
An adjustment has also been introduced into the NHS funding formula to ensure that extra resources go to areas of highest health need.
What does the future hold?
The Labour government has made substantial efforts to increase the attention given to health inequalities as part of wider health policies.
Its welfare reforms have raised the living standards of some of the poorest groups, but inequalities in income and living standards continue to widen. Around the world, income equality remains a strong indicator of good population health.
The health of the population as a whole has improved, but wealthier people have benefited more than poorer people, and inequalities in life expectancy and rates of disease still persist.
Some argue that more time is needed to reverse the inequalities trend and that it is unrealistic to expect demonstrable progress so soon.
Others feel that, if a higher priority is not given to measures to reduce socio-economic inequalities, the chances of significantly reducing health inequalities in the next decade will be slim.
