Have we lost the battle to improve health inequalities?

Health inequalities have ceased to be fashionable. From a position where the goal to reduce inequalities was a core objective of the health system – with national targets to reduce them by 10 per cent – we have seen it steadily marginalised. In a few short years the goal of social equality in health has been reduced to trying, not very hard, to ensure decent access to health care for those in the most disadvantaged groups.

The mandate from the coalition government to the NHS Commissioning Board does mention inequalities five times, but the subject isn’t mentioned in any of the outcome areas and there is no hint of what the government expects the NHS to do to reduce the profound health inequalities that have been so well described and documented over the past decade. The recent abolition of the short-lived Cabinet Subcommittee on Public Health (due to a reported lack of interest from other government departments) does not bode well for the sort of cross-government working that is clearly necessary for the reduction of health inequalities.

In the foreword to his landmark 2010 report Fair Society – Healthy Lives, Michael Marmot wrote 'the more favoured people are, socially and economically, the better their health'. The report identified that children and young people should be the highest priority if we want to reduce health inequalities. There is little that the NHS can do by itself to reduce inequalities, but it could do what it has never done before and exert its societal authority as a collective organisation for which the English population has enormous respect.

Imagine the effect if all the paediatricians, GPs and health visitors campaigned actively in every constituency to reduce childhood obesity. 38 per cent of primary school children travel to school by car in England; a campaign to make it safe for every child who lives within half a mile of their primary school to walk or cycle instead could have major benefits. Not just for children of course – liveable towns and cities with walkable streets would deliver benefits for everyone, particularly in reducing the isolation of older people. It would also reduce the 13,000 deaths from air pollution every year. It is of course the poorest families that live in the worst environmental conditions so the benefits would particularly accrue to the most disadvantaged.

There is little doubt that the leading cause of health inequalities is smoking. We have done well to reduce smoking, but the rate has levelled off at about 20 per cent of the population. The key task now is to halt the recruitment of new smokers. Tobacco use is a paediatric epidemic, and if we can stop the tobacco industry gaining new customers then smoking will go into inevitable decline. NHS smoking cessation services won't give us our first smoke-free generation, but a gloves-off war on the tobacco industry might.

The health professions have led the fight against tobacco, rallied for seat belts and crash helmets and spoken out against alcohol abuse. It is but a step – admittedly a big one – for us to take up the cause of children and young people in bold and innovative ways. But we need new thinking if we are to reduce health inequalities. Where will this come from at a time when the NHS is being turned upside down by an unwanted, unneeded and deeply unpopular re-organisation? Can we add health advocacy to the duties expected of health professionals and a social conscience to the attributes of NHS trusts?

At the close of the foreword to his report Michael Marmot quoted a prescient line from Neruda's collection The Captain's Verses urging action 'against the organisation of misery'. If ever there is a time for collective action it is surely now.


#39932 stephen black
management consultant
pa consulting

The NHS has to face several major issues when dealing with inequality.

The first is naivety about cause and effect. Poor people typically have worse health and, historically, this has led to much more NHS spending in poorer areas. But the NHS has little influence over the causes of inequality and the spend does little to reduce inequality. And the extra money also shows a poor return on investment in improving health.

Secondly, Assuming that health inequality is an NHS problem may actually distract from useful investment. Some people have argued that housing quality is a major cause of poor health. So fixing social housing might give ten time the return than the same spend by the NHS. Or adopting a planning policy that drives down the cost of land and housing thereby making good housing more affordable even without much government spend.

Third, all public health policy has to confront the fact that the ability to coerce people into acting healthily is limited in a free society. For example, We cannot stop people choosing to smoke (and it is naive to believe that people only smoke because an evil industry has persuaded them too, after all we have never advertised illegal drugs yet they are as used as tobacco). Maybe free societies have to live with some inequality because different people make different choices.

Government does have some duty to make sure children are not locked into choices by their environment or their parents. But we need to have a much better idea about cause and effect. Maybe the highest impact would be an education system that promotes social mobility, or policies on housing designed to enable anyone to move job and home easily rather than one designed to make the already rich even wealthier.

#39933 Jessica Allen
Deputy Director
UCL Institute of Health Equity.

Gabriel Scally makes welcome and important points. None more so than to stress that we must do more to ensure that the devastating waste of life and health we see across England becomes a central national Government Priority and far greater focus of activities. All too often good intentions about tackling health inequalities slip off political priorities. The difficulties and supposed costs of reducing health inequalities, which have their origins in wider social, environmental and economic factors, overwhelm even the best intended.
The Institute of Health Equity are, in March, launching a report and programme of actions, building on commitments made by medical royal colleges, BMA and others to deepen and develop the NHS role in tackling wider social determinants of health. We hope that this will contribute to efforts to tackle health inequalities and to build the necessary momentum and advocacy to get greater national government action. Public health, employers, schools, children centres, housing, planners, transport teams, we need you too.

#39938 James Nicholls
Research Manager
Alcohol Research UK

Given that tobacco is mentioned here, and obesity has been in all the papers in the last couple of days, it’s worth pointing out that social inequalities also play a very significant role in relation to alcohol harms. According to recent research by Health Scotland, alcohol-related acute hospital discharge rates in the most deprived areas were 7.6 time higher than in the least deprived quintile. Crucially, this is despite the fact that levels of consumption are similar across the social spectrum – indeed, according to most measures, generally lower among the less well off.

The reasons for this remain very unclear. It is undoubtedly tied to the other drivers of health inequality that have been mentioned elsewhere: poor housing, diet and so forth. However, there are other possible causes: different patterns of consumption, different levels of health care, or even harmful drinking exacerbating poverty. It may also be that different social groups report their consumption differently. We don’t know for certain, and yet understanding this paradox is critical to developing effective policies and interventions.

Over the next two years, Alcohol Research UK are funding a flagship research project with the North West Public Health Observatory investigating this issue. It is hoped that the findings will go some way towards explaining this phenomenon. The relationship between alcohol, deprivation and health cuts across some of the most pressing public health challenges, so understanding it better is critical.

#39941 Luke
Ex Healthy Schools adviser

Health inequality is not helped by current Dept. of Ed policy. The focus on child health and wellbeing has been allowed to slip and support services for schools have reduced with it.
Much of the hard fought gains by the Healthy Schools programme et al have been lost. This leaves disadvantaged young people in a much worse place for the future.

#39943 Peter Baker
Men's Health Consultant

Gabriel Scally is spot on. The government's rhetoric about tackling health inequalities is daily undermined by its actions on welfare benefits, housing and taxation as well as health service delivery. But it's not just about socio-economic inequalities - those linked to race, disability, gender, etc are also critically important. In my field, men's health, over 40% of male deaths are premature (under 75 years) compared to about a quarter of female deaths. Men are 60% more likely to develop and 70% more likely to die from a cancer that can affect both sexes. Statistics out this week show that male suicides remain at three times the level of female suicides, and that male rates are now rising again. All these inequalities need to be systematically tackled by deeds, not words.

#39945 Edward Harkins
Knowledge & Research Associate

I'm currently much in favour of the Community Asset Transfer approach. Give the various communities of residence, themes and interest, the: assets; autonomy; resources; powers; and support, with which they could take on the identification and implementation of fundamental solutions. The 'communities' themselves are often the most informed 'experts' in; what the problems are; where they originate; and what makes them inter-generational and mutually-reinforcing. The whole The health 'professionals' and other producer interests, along with politicians, have been given immense public funding resources for a very long time - and we have arrived at being a society with some of the most acute and unjustified health inequalities among advanced economies. I helped deliver and facilitate a conference on the theme in Glasgow for the RSA Scotland several months ago. The clear consensus was that the various communities were 'up for' the Community Asset Transfer approach - but the barriers lay with many of the health professionals (with honourable exceptions such as Sir Harry Burns), official agencies such as Community Planning Partnerships in Scotland and - above all - politicians at national and local levels. One essential factor in radical and fundamental change will be autonomy for the individual as well as the community in which the individuals resides and/or woks and/or is a service user.

#39946 Mary E Hoult
community volunteer
The Community.

YES I do think we have or will lose the battle to reduce inequalities. To give you a small example,I have attended the my local NHS Trust board meeting held every month for years, am only one of a very few public that attends, recently the timing has been changed which will make it very difficult for me or any of the general public.Winter start time 8.30 Summer start time 10.30 .I explained that to be able to attend now I would have to leave home about 7.30 get two buses and would be unable to use my Bus Pass so I would have to Pay.I also have an eye problem and don't see very well in poor light as such I asked if the timing could be reversed,, early start in summer late start in the winter but no such. Luck inequalities can only get worse under the current situation

#39947 Christ Manning
Senior lecturer
Kingston University

The relationship between social ffactors and health is clear and it is interesting that the current government dismisses a proposal from the opposition to link health and social care budgets, with a greater role for local authorities, because it will be "taking power away from doctors and nurses". This is what we need isn't it?

#39948 Michael Bowen
Director of Research

Stephen seems to be heading in a sensible direction in his reponse to this. In a capitolist, democratic society it is not feasible to remove all sources of inequality. The health service shold be focusing on the job of providing well designed, efficient, evidence-based services that are as easily accessible to everyone as can reasonably be achieved. The historic insistence on completely separating functions such as health, social care and education has limited our success in addressing many of the issues that underlie the differences in health outcomes that we regard as inequalities....the small moves toward better integration and reduced barriers across these areas have been drastically insuffient to address the problems. To signficiantly improve health outcomes and move the levels of inequality toward a more acceptible level, education seems to sit at the heart of things. If we improve educational outcomes across the board, it seems probably that we would see concomitant improvements in social welfare, economic success and health....Yet we seem quite content to continuously allow politicians to tinker with the education system rather than promoting and supporting trained professionals to develop evidence-based practice in education. We a content to see budgets for eduation cut and investment programmes in schools and universities reduced or cancelled....Worry about health outcomes, while we fritter away the future of the whole country by standing still and watching as we slide down the international table of educational performance seems disaterously and wilfully ingnorant and foolish. By all means invest in health research and services - of course this is needed, but it will be through raising the educational attainement of the entire population to the greatest potential achievable that will ultimately move us toward improving population health on a large scale....

#39949 jan Smithies
Bradford MDC

This is from my (frustrated) perspective as an ex member of the DHs 'Health Inequalities National Support Team' (made redundant on my return to PCT land an alas given no opportunity to share valueable learning from the HINST work) and now an elected member. I am battling to keep it high on the local agenda - motion to Council, constantly raising issues via Scrutiny etc, but it is like starting from point zero. There is no shortage of agreement that 'we need to do something' but very little comprehension of what, and especially in terms of a planned, targetted, evaluated approach. Altough it could be said I have a personal bias, having been part of the HINST team, I do feel Prof Chris Bentley and the rest of our team were really begining to come up with enough examples of measurable impact practice, and frameworks to assist people to focus action plans.

Health inequalities cost lives, limit quality of life and are bad for the economy - in local govt and nationally.

#39951 Michael Roy
Glasgow Caledonian University

I should caveat what I’m about to say is written with Scotland in mind, but could equally apply to the rest of the UK: we are simply reaping the rewards of our economic policy which is determined in London. I should also say that I’ve written extensively on this subject so have been able to come up with the following more or less “off the shelf” from stuff that you might see of mine elsewhere if you look hard enough.

Article 25 of the Universal Declaration of Human Rights 1948 states that “Everyone has the right to a standard of living adequate for the health, and wellbeing of himself and his family…” The Preamble to the World Health Organisation’s (WHO) constitution also declares that it is one of the fundamental rights of every human being to enjoy “the highest attainable standard of health” where health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
So it is absolutely correct to say that the problem of stubborn, and even widening, health inequalities are not just a national disgrace, but arguably a breach of many citizens’ fundamental human rights.
Health is, as has been said, very largely socially determined, with people in more affluent areas living longer and having significantly better health. Marmot and others have blazed this trail for 30 years or more.

In Scotland, average health life expectancy is around 18 years lower among people in the most deprived areas compared with those in the least deprived areas. That’s an average figure however. Males in the most deprived areas of Glasgow can expect to live significantly shorter lives than the average life expectancy in the Gaza Strip or Iraq.

And while health inequalities blight most developed economies, there is a direct relationship between the more unequal a society is and the extent of the problem. The UK is the fourth most unequal country in the developed world behind the US, Singapore and Portugal.

But even Portugal outperforms Scotland in terms of life expectancy.
And it’s been getting worse and worse and worse. As someone else pointed out, health inequalities have been accelerating in line with social inequalities generally: the current austerity measures employed by the coalition Government in Westminster can only make things worse for the poor, with inequality not seen at such levels since Victorian times.

And don’t think I’m letting Labour off the hook. Social mobility has been in decline since at least the 1950s and no Government has seriously tackled it, to the extent that social mobility in the UK is now among the lowest in the developed world.

It is therefore a mistake to think that the inequalities are simply something that can be “cured” by our hard pressed health services alone. While programmes aimed at changing health behaviours or risk factors, such as on smoking or breastfeeding are important, these often have the perverse effect of widening health inequalities because the people who best respond to these messages are not the most deprived.

The idea that the NHS can impact upon health inequalities is about 60 years out of date.

The problem is deep seated, systemic and within the ambit of ALL Government departments, in both central and local government. It's not an education issue alone, as someone suggests. It involves action by business and by wider society – particularly action by the Third Sector which is often closest to the communities it exists to serve.

Poor health is merely a symptom.

This is a social justice problem.

And that’s where the problem (and thus the solution) lies.

The principle policy driver of Government in the UK (and Scotland is the same, despite our supposed left of centre Scottish Government) has been about “creating the conditions for sustainable economic growth”.

But why?

Why is sustainable economic growth of such paramount importance?
I’m not saying that economic activity is not important. Of course taxation revenues from business (the ones that actually pay taxes) are vital to funding public services. And having a job (or, more accurately, a purpose in life) is one of the single most important factors to human health and wellbeing.

But it’s not the only factor.

As Edward said earlier, Scotland’s Chief Medical Officer, Sir Harry Burns, has been working for a number of years to turn attention to “assets based” approaches to public health: focusing attention on those factors that stop us getting ill in the first place (rather than community asset transfers, which only a small facet of this). We are talking about factors that are well known to have a significant impact upon health and well-being: such as having a good network of friends and social networks (of the real variety, rather than virtual followers on Twitter or Facebook); healthy and supportive relationships; having access to learning opportunities, and good education and skills; feeling safe and that people can be trusted; being able to think clearly and function socially; live a healthy lifestyle; having access to quality public spaces; having a good sustainable local economy with access to quality local produce ; access to the arts, being able to express yourself (if that takes your fancy) in a creative way.

So why don’t all of these “assets” get promoted by government to the same priority as the rest? Why do we emphasise “sustainable economic growth” over everything else?

The problem, as someone earlier said, is the type of capitalist economy we have created.

In 2008 the World Health Organization’s Commission on Social Determinants of Health reported their findings and recommendations. This Commission had a stellar cast drawn from a whole range of disciplines, including two Nobel prize winners in economics – Amartya Sen and Joseph Stiglitz. It was chaired by Professor Lord Michael Marmot, probably the world’s leading expert in this field.

Their report Closing the Gap in A Generation doesn’t pull any punches. It’s full of enough bite sized quotes for elected representatives to plunder for years to come.

Such as (from the back cover):
“Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative. Social injustice is killing people on a grand scale.”

Social injustice in the UK is killing people.

But a manifesto to address this particular issue could be unashamedly cribbed from the recommendations contained in the Closing the Gap in A Generation report. (I’m working on the assumption that if you have won a Nobel Prize you’re pretty smart and probably know what you’re talking about).

The principal priority of the Government needs to be amended to “Creating the conditions for the citizens of England, Scotland, Wales and Northern Ireland to live happy, healthy and fulfilled lives”.

We then implement (in full) the three overarching recommendations of the 2008 Commission report:

1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money, and resources
3. Measure and understand the problem and assess the impact of action

If we think about framing ALL of our spending powers towards tackling the social determinants of health, instead of thinking of it as something that the NHS and local authorities do, then we can actually start tackling this problem once and for all. Tackling the inequitable distribution of power, money and resources for instance, will require a move towards a more Scandinavian style welfarist, high taxation, social democracy. We might have an opportunity to create such a society if we in Scotland achieve independence, but there is no appetite for such an approach in the policies of any of the mainstream political parties.

Measuring and understanding the problem will require the type of total systems approach that we currently can’t even begin to imagine in the UK (but is being tried elsewhere, such as in the state of Victoria, Australia)

A final thought: another quote from the Commission’s report (this time inside the front cover):

“The development of a society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health”

On this measure, can the UK really consider itself a developed country?

#39954 Brian
Nhs manager

Until the nhs admits its inequality in how it recruits and treats diversity itself health inequalities will remain. As the nhs shrinks it becomes more beige.

#39955 David Truswell
Senior Project Worker
Central & North West London Foundation Trust

Anyone who got into or is staying in the field of health inequality because it is 'fashionable' best leave now.

National economies work out through the employment and purchasing activities of millions. Health inequalities cost millions as they impact on employment and sickness rates, skew health care towards high overall costs through late prestentation and late, less effective treatment and undermine efforts to make people proactively manage their own health. If health inequalities predominate in lower income brackets, then in circumstances where the economy is contracting, as more people are getting poorer and so getting more ill there will be greater impact of health inequity. Please point out the errors in my math.

#39957 Catherine Pratt
Project Manager - Health
Design Council

Raising the value people place on their health and encouraging people to make better health choices can go some way to reducing the negative effects that are caused by health inequalities. If we can encourage today’s children to grow up making better health and lifestyle choices we will undoubtedly see the benefit of this in future generations.

The Design Council are currently working in partnership with Guy’s and St Thomas’ Charity and the London Boroughs of Southwark and Lambeth to explore opportunities to improve the health and wellbeing of children under five in those boroughs.

Michael Marmot’s review has been a key inspiration for our thinking on this programme. Our work will explore approaches that increase the value that families place on their health and wellbeing to enable better outcomes for future generations.

Find out more about The Knee High Project on the Design Council website.


#39962 Mark Gamsu
Visiting Professor
Leeds Metropolitan University

Its great to see Gabriel Scally championing the need to focus on Health Inequalities - and respect to him for getting the debate going - but..... I think his emphasis is wrong - as will be clear I have a lot of sympathy with Stephen Blacks views.

First - lets be clear about the causes of health inequalities - it is dispiriting to hear yet again the old trope 'smoking is a leading cause of health inequalities'. That is just not true - there are higher levels of smoking among the most disadvantaged - but the cause of that is to do with inequalities in power, resources and opportunity. A failure to acknowledge this leads to a misguided focus on trying to force/persuade/lecture the poor on changing their behaviours while doing little to address the circumstances in which they live.

Second - 'imagine the effect if all health professionals campaigned actively to reduce obesity'. Yes I would like to see more campaigning but this has to start with the public themselves - despite the relentless attack on working class organisations such as the trade union movement and the reckless cutting of resources for grass roots community groups this is were we need to be building from. Peoples lived experience - and there are plenty of examples of where this is happening. We need to support the development of a genuine community led public health agenda. This will actually mean working with local communities priorities first - and these may not be obesity or smoking - but debt, poor housing, lack of opportunities for social mobility, social isolation etc. Actually focussing on these will build the base for addressing traditional public healths more parochial concerns.

So - lets see more health professionals out there in communities responding to community agendas first rather than imposing their own. We can build here on the work of people like Hazel Stutely (Health Empowerment Leverage Project), Turning Points Community Health Researchers, Well London, Altogether Better and Unlimited Potential to name just 5!

#39964 Brian Dow
Director of Communications
Royal College of Paediatrics and Child Health

It is probably fair to say that medical professionals have not always realised the power they possess in affecting wider social change and, in particular, the extent to which that power is amplified when it, the profession, speaks as one. It is certainly hard for vested interests to look anything other than that when doctors of all disciplines come together to speak on behalf of the patients, whose lives they dedicate themselves to treating and that was certainly part of the intent on the part of the Royal College of Paediatrics and Child Health when we chose our name 16 years ago. We aim to be a college for patients as well as professionals and our members see it as their role not only to deal with the individual case which comes through the door but also to advocate on behalf of all children to make sure, where it is possible to do so, that preventable illness is precisely that – preventable.

That’s why we have been working very closely with our colleagues across the medical professions under the Academy of Medical Royal Colleges to produce a major report on obesity, across the entire population. The starting point was a clear understanding that collective action is necessary to achieve the sort of big ticket change that is required on what is one of the biggest threats to public health and health services now and in the future.

#39965 Gabriel Scally
Professor of Public Health and Planning
University of the West of England

Great contributions and a several excellent points made.
I do need to take up Mark Gamsu's comments about smoking. It was more prevalent amongst the wealthy in times past and is now more prevalent in the most deprived groups. It is an enormous contributor to premature mortality. I am not indulging in vicim blaming to state that. Indeed, in my blog, I made it clear that I favour an outright attack on a tobacco industry that is unscrupulous and exploitative. They are making billions out of human addiction and illness. There are few measures that would be as effective at putting money into the pockets of the poor as achieving big reductions in smoking.
Mark's second point about the role of health professionals is an important one. I believe that health professionals should be active participants in the communities in which they live and practice. I particularly believe that the Director of Public Health should be a well known figure in the communities that he or she serves. The job of health professionals should be to help people take control of their own lives and that means working with them to empower and improve communities. I am enormously impressed by Asset Based Community Development (ABCD) and think the approach should be be part of the knowledge base of health professionals.
Thanks to everyone who has commented so far.

#39991 Laurence Moore
Professor of Public Health Improvement
DECIPHer, Cardiff University

It seems that England in particular is in need of #publichealthsuperheroes to advocate for evidence based action on public health and health inequalities in particular, with a focus on cross-Government action to give children and young people the best start in life being an obvious first priority.
Alas, a reliance on decision making based on power, a quick buck and the Daily Mail tends to relegate these rational priorities to the end of the queue.
Devolution is bringing about sharp differences here. Scotland has been leading. Now in Wales, the recent social services and wellbeing bill guardian.co.uk/society/2013/jan/29/wales-found-winning-formula-healthcare?CMP=twt_gu
and consultation on a public health bill wales.gov.uk/docs/phhs/consultation/121129consultationen.pdf
are both promising in paving the way for more joined up action to improve health and well being, highlighting health inequalities as a focus and recognising the inadequacy of relying on the NHS and individual agency to improve health and wellbeing.

#40008 Jeremy Segrott
Research Fellow in Public Health
DECIPHer Centre, Cardiff University

Will be interesting to see how the diverging health systems of the UK nations look in five years time. Your piece seems to highlight the importance of acting across different policy areas and organisations, but also of having integrated national systems. And it seems essential to emphasize, as you do, the importance of promoting the health and wellbeing of children and young people.

#40010 Judy White
Drector Health Together
Leeds Met University

Great to see a debate on tackling inequalities which as Gabriel Scally says has rather gone off the agenda, but I want to pick him up on his response to Mark Gamsu who challenged his view that smoking is the greatest cause of health inequalities. The point Mark was making, quite rightly in my view, is that poorer people smoke more because of 'inequalities in power, resources and opportunity'. As these inequalities grow in a period of recession and austerity, it is more important than ever that we focus on the 'causes of the causes' of health inequalities rather than their manifestations in smoking, poor diet etc. And to do this we need much more engagement with communities working with them to build on the assets they have as Gabriel rightly points out. Public Health professionals should also be making as much noise as possible about the dire effects that welfare reforms and austerity are having on poor communities as these will surely lead to a widening of inequalities in health.

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