Good progress? The coalition’s track record on inequalities in health

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One of the early mantras of the coalition government was the intention to ‘improve the health of the poorest, fastest’. So where have we got to with this ambition, and more broadly, with inequalities in health?

Back in 2010 and 2011 there was optimism about the role of outcomes frameworks in tracking and holding the NHS, public health and social care systems to account. With strong frameworks driving transparent progress, and with a commitment to inequalities at their heart, there was hope that reducing inequalities in health would be central to policy, practice and public debate about the NHS and health. The Health and Social Care Act 2012 introduced new legislation beyond the public sector equality duty, legally binding the NHS and wider system to have due regard to inequalities in health. In our mid-term assessment of its health policy we gave the coalition the benefit of the doubt.

Now it is time for closer scrutiny. There have been positive changes, NHS England – taking advantage of its new arms-length role from the government – has recently decided to give greater weight to deprivation in its resource allocation formulae. This approach is not simply of arcane academic interest, recent research suggests that sending more of the NHS allocation to more deprived areas accounted for an 85 per cent reduction in the gap in mortality amenable to health care between 2001 and 2011. NHS England too has very recently made strides in its commitment to equality in its workforce, through the Workforce Race Equality Standard.

However, once you stand back, it is obvious that there is no over-riding strategy behind some useful piecemeal changes. Inequalities in health are cross-cutting complex issues that require coherent cross-system action and leadership. The fragmentation wrought by the health reforms has made any coherence of leadership on inequalities of health all the harder.

The last government was off-track to meet its own targets on reducing inequalities in life expectancy when the coalition abolished them; although in its assessment of these targets the National Audit Office did recognise a system-wide, coherent attempt to tackle them, despite serious issues of delay.

It is hard to claim the same coherent approach to reducing health inequalities for the coalition government. Despite early rhetoric and welcome legislation, the outcome has been a clutch of disconnected, under-powered sub-strategies and initiatives. These range from Public Health England’s rather late-in-the-day ‘national conversation’ to NHS England’s 13-page strategy document released at the end of a board meeting. Meanwhile, there has been virtual silence from the Department of Health and little sense of it holding the system to account for inequalities in health, despite the new legislation. Some of this can be explained by the fragmentation in system leadership for health inequalities.

It is also hard not to conclude that it was assumed that setting up Public Health England and giving more responsibility to local government for public health, each welcome in their own right, would ‘sort’ inequalities in health. But if this was the case, the government’s flagship health premium incentive scheme to reward local authorities for reducing inequalities, turned out to be an incentive of £5 million between all 152 local authorities. There is little point in introducing such incentive schemes, if you don’t then put your money where your mouth is.

On health outcomes there have been improvements in some measures. Life expectancy has risen faster for newborn boys from deprived local authorities than for less deprived ones, although the opposite is the case for newborn girls. However, the latest data compares the situation between 2010-12 with 2006-8, so most of this will if anything reflect the effects of the previous government’s policies and spending, rather than those of the coalition.

More recent indicators on access to care, arguably more under direct NHS control, show little movement in the over-representation of people from black and black British groups among those detained under the Mental Health Act. The excellent NHS Atlas of Variation continues to show how the services that people receive differ around the country. Perhaps most strikingly of all, Office for National Statistics data shows huge gaps in healthy life expectancy between clinical commissioning groups, up to 18 years for men, and 20 years for women, and the latest data, in helpful interactive map form, shows similar figures between local authorities. Again, while much of this predates the coalition, the policy and practice response to it has not been commensurate with the scale of the problem.

Finally, there has been far too little attention paid to the impact of austerity on health. The NHS can do much more to tackle poverty and the wider determinants of health. Beyond the NHS, the government seems to have largely ignored how wider public spending decisions affect health and health inequalities, and it has abolished its own cross-government sub-committee on public health.

Reducing health inequalities is one of the hardest challenges that any government has to tackle, and the recent record of all governments of whatever colour has been patchy at best. The coalition’s own brief assessment of its record is buried in the Department of Health’s annual accounts, stating ‘good progress’ has been made to ‘embed action on inequalities across the system’. There is some truth in this, including legislative change and the Workforce Race Equality Standard. But across the term, the lack of a coherent strategy and translating that into accountability means the initial rhetoric has not been lived up to.


stephen smith

retired research fellow med science,
Comment date
10 April 2015
Well I suppose a few people are holding their breath to see what the election will bring. There's a slow awareness by the general public, I suspect, of some of the changes creeping in, fuelled by 38 degrees, KONP and similar organisations. As you've indicated, looking back over this turmoil from about 2020 towards 1948 should be interesting.

Harry Longman

Chief Executive,
GP Access Ltd
Comment date
10 April 2015
Good summary but sad story of fine words and no buttered parsnips. A let down for Britain's neediest populations.

Dr S. Michael …

Comment date
10 April 2015
What surprises me about this is the lack of detail, both in the blog and in the Nutshell, about how patients access healthcare. There was little in the Atlas of Variation which shows what is known.
As an oncologist who researches Cancer Registry data I appreciate that we know much more about how cancer patients gain access – but even then, there is little discussion of these points in planning services.
Cancer registry data include Index of Multiple Deprivation (IMD) data for the Lower Super Output Area (LSOA) of the patient’s residence. This is not information about the individual but about the very immediate neighbourhood. With this information we know that the risk of death in the first year from colorectal cancer increases sharply with increasing deprivation. We know that the chance of having any treatment decreases with deprivation. We know that the chance of receiving radiotherapy decreases with distance from the radiotherapy centre – radiotherapy being one of the first NHS services to be centralised in the 1960s following the 1960 Hospital Plan. Another service so centralised was thoracic surgery and for non-small-cell lung cancer patients the chance of undergoing an operation, by far the best chance of cure, decreased both with distance from the Centre and with increasing deprivation.
As the NHS becomes ever more cost-conscious and “demand management” strategies are designed, the aim is to use services less. But in the competition between patients for resources how precise is the discriminant - in each case – that says who gets the test/treatment? One feature that is very clear is that pushy affluent people are better at pressing their case for access than the poor; this includes tests for cancer. When a service is centralised, those people for whom the flash new service is more remote are less likely to use it; I have seen several examples of patients denying themselves the benefits of radiotherapy because of travel issues. These have much less significance for Jaguar drivers!
We know much detail about underuse of cancer services because of registration. This must be the tip of the iceberg given that most parts of the NHS do not have the wealth of population-level detail that registration provides.
The Service that we are designing to cope with the pressures of austerity is NHS-MC. The NHS for the middle classes. I challenge the NHS to compare access to services by those with LSOA IMD20, the poorest 40%. I challenge the King's Fund to inform us all of the outcome.

David Buck

Senior Fellow,
The King's Fund
Comment date
13 April 2015
Dear Dr Crawford,

First, many thanks for taking the time to post your comment. A quick response. The first thing to say is that squeezing an overall assessment into the space available for a short, accessible blog inevitably means we cannot cover all the evidence and experience on all topics and levels of analysis. This is an overview, but i think one that is valid and appropriate.

I agree with you on the benefits of using small area data, and great that you are using this in your own work on cancer. In Autumn last year i was fortunate to chair an ESRC seminar on the use of data for inequalities in health research, many of those studies too were using such data, you can see more on this event and wider initiative and links to the research it led to here

In the summer we will also be publishing research on inequalities using similar data, so i hope you will find that of interest.

Dr Jonathan Sexton

Retired Public Health Consultant; CCG Lay Member,
Canterbury and Coastal CCG
Comment date
14 April 2015
An important and timely policy analysis with depressing albeit predictable conclusions.

The truth is that the coalition government, especially the dominant Conservative element have had little interest in seriously addressing health inequalities, since to do so would run counter to the intention to 'shrink the state' under the dogma of 'austerity'. They expressly rejected the recommendation of progressive taxation by the Marmot Review (2010).

Health Inequalities boasts an impressive evidence base. However it requires political will to steer the multitude of contributing players into a proactive coherent programme, which has clearly been lacking. The previous government can be blamed for their programme shortcomings but at least there was a plan, which Makenbach and others commented at least favourably upon from a WHO European perspective.

Added to which has been the neutering of public health practice at street level through its transfer to local government. There is little scope for PH truth speaking unto the power of elected local politicians if they don't like the necessary political messages directly or indirectly, or see the people who need the help of reductive programmes such as Sure Start as 'not our people'; or make a distinction between deserving and non deserving poor.

Unless the root causes of health inequalities are addressed through centralised directive and coordinated action, there is little hope for the treatment services of the NHS to make very much impact, other than to deal with the consequence of social dysfunction manifesting itself in disease.

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