Health inequalities have been a controversial issue for many years, and debates on the origin of inequalities are highly polarised: which forms of inequality matter; whether we should aspire to reduce them and, if so, how we could do so most effectively.

The first quantitative study demonstrating unequal health outcomes between different socioeconomic groups in the UK was written by Frederick Engels in 1845. One hundred years later, many believed that the establishment of the NHS would inevitably lead to these gaps being closed. From the 1970s onwards, however, it became increasingly clear that this had not happened, with research studies demonstrating that health inequalities had persisted despite the provision of health care for all. 

In 1977 the Labour government commissioned Sir Douglas Black to review the evidence on health inequalities. The report concluded that the NHS by itself did not have the power to eradicate health inequalities; instead, broad social change and action across various policy areas would be required. Although the new Conservative government elected in 1979 did not accept the recommendations of the Black Report, the report had a significant impact on academic and political debate throughout the 1980s and 1990s.

A similar review was commissioned by the incoming Labour government in 1997. Donald Acheson’s Independent Inquiry into Inequalities in Health found that despite a general downward trend in mortality over the two decades since the Black Report, inequalities had persisted or widened, with higher socioeconomic groups having experienced a faster decrease in mortality. The Acheson Report made 39 recommendations for action across a wide variety of policy areas including health, education, housing and welfare.

In 2001 the Labour government’s response to the Acheson Report included targets to achieve 10 per cent reductions in two areas of health inequalities by 2010: in the gap in infant mortality rates between socioeconomic groups, and in the gap in life expectancy between those living in deprived areas and the general population.

The first comprehensive strategy on reducing health inequalities was published by the Department of Health in 2003 – Tackling Health Inequalities: A programme for action. This sought to create a basis for long-term, sustainable reductions in health inequalities, identifying new and existing programmes that would help to reduce the gaps between different groups. It included proposals targeting individual behaviour, alongside ‘upstream’ approaches to address underlying determinants of health such as employment, welfare and housing.

From 2004 onwards, the previous government's policies gave greater emphasis to the role of individual choices in causing illness and maintaining health inequalities. Upstream approaches have continued to be implemented, but overall, policy documents such as 2004’s Choosing Health have focused more on individual behaviour change.

A review of progress on reducing health inequalities published by the Department of Health in 2009 acknowledged that the data shows no narrowing of the gaps since the targets were announced. However, it argued that this data fails to capture progress that has been made, concluding that while much has been achieved there is still much more to be done.

To inform future strategy after 2010, the Labour government commissioned a major review on health inequalities led by Professor Michael Marmot, Fair Society, Healthy Lives. This report was published in February 2010 and recommended six areas where policy should focus to reduce health inequalities.  The Marmot review emphasised the role of a healthy start in life, education, employment, welfare programmes and pro-active prevention to address health inequalities and recommend broad-based action on these. 

The shifts over the last decade between approaches focusing on ‘upstream’ social determinants and those focusing on individual-level determinants highlight the many unanswered questions in health inequalities.  There is good evidence that health inequalities are not caused by individual lifestyle choices alone; for example, there is a marked social gradient in the prevalence of mental health problems in children, with those from the lowest socioeconomic groups experiencing three times as many mental health problems as those from the highest. It is unlikely that lifestyle factors could account for this discrepancy.

However, the question of whether it is more effective to target policy and interventions at the immediate causes of health inequalities or at the upstream ‘causes of the causes’ remains open. This is a question that is partly about the effectiveness of different interventions, but also partly about values: how highly we value changes achievable in the short-term versus potentially more fundamental changes that are likely to take longer to achieve.

There are also unresolved questions regarding which forms of inequality ‘matter’.  Should the policy aim to achieve equal health outcomes for all groups in the population or simply to ensure that there is equal access to health care for equal need?  Alternatively, some argue that policy should focus on improving outcomes for all, without regard to the gaps.

The current economic downturn can be expected to exacerbate health inequalities, both by increasing the social problems that underlie inequalities (eg, unemployment) and also by potentially reducing budgets for the NHS and other public services.