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