Reducing inequalities in health: towards a brave old world?

First, at the launch of the Health Profile for England, John Newton (Public Health England’s Director of Health Improvement) presented data that showed there had been little demonstrable change in health inequalities since 2010-12, as measured by gaps in life expectancy and healthy life expectancy by levels of deprivation. 

Second, transparent but buried deep in the Department of Health’s annual report, there lies an assessment of how the Secretary of State is meeting his duties on health inequalities in England. This includes the Public Health England data, but is also a much wider assessment, across 15 indicators from the public health and NHS outcomes frameworks. This data is reproduced in the Table below and shows that inequalities on all 15 indicators have widened since baseline measurement and, for 9 of the 12 for which there have been some mid-point measurements since baseline, the latest data shows widening since that mid-point.

Table: Latest trends in public health outcomes framework and NHS outcomes framework health inequality indicators 

^{* The slope index of inequality is the range between the most and least deprived parts of the population, based on the line of best fit across deprivation deciles. It takes account of inequalities across all deprivation deciles, not just the most and least deprived. Further information on the slope index of inequality can be found in NHS Outcomes Framework Indicators for health inequalities assessment.}

^{Source: Adapted from Table 8, Department of Health Annual Report and Accounts 2016 to 2017. Last two columns are The King’s Fund’s summary of the differences between the point estimates in Table 8.}

Looking at this data, you would be forgiven for thinking that there is an unwritten rule for inequalities in health: that everything always gets worse. But, cheeringly, you would be wrong; the third piece of the jigsaw is Barr and colleagues’ important study that sought to discern whether the last Labour government’s strategy on health inequalities – a comprehensive cross-government and NHS-focused approach – had had any effect, as measured by relative and absolute differences in male and female life expectancy at birth between more and less deprived local authorities. Unusually, the findings are cautiously positive. Over the period the strategy was active (late 1990s to 2010), those areas subject to the interventions in Spearhead areas and those more broadly defined as deprived saw a narrowing in the life expectancy gap with the rest of England, reversing the previous trend which reasserted itself once the strategy ended. This finding seems to stand up to a battery of statistical tests and alternative formulations. A study like this can never be perfectly certain because it's about assessing policy with many moving parts, but it is a very good attempt to draw out the overall impact from an extremely complex policy environment for which the authors should be applauded.

This is all the more interesting because by the end of the Labour government it was widely thought that the life expectancy target for Spearheads would be missed, although data lags meant that was never officially confirmed. By the time the data was available the coalition government had dropped the target approach to health inequalities – and the measurement, reporting and supporting mechanism behind it – as part of its ‘bonfire of targets’.

While there were some early signals after the Labour government left office that its approach may have been starting to have had an effect on some measures of inequalities (in particular by reducing within-area inequalities in the Spearhead areas) and our own analysis also suggested some improvement, Barr and colleagues have now looked at this properly and in the round. Their analysis is one that should be welcomed as enormously encouraging by pragmatists of all political persuasions for showing that inequalities in health, in all their undoubted complexity, are amenable to change by policy actions. 

So what, overall, should we take from this seemingly contradictory slew of information and analysis? Well, that health inequalities can be measured in multiple ways in terms of proxies for health, dimensions of inequalities, at various levels of geography and over different points in time. It is therefore possible that different measures will show different things; it’s how they fit together that tells the overall story. 

That story, at least for me, is a consistent one. First, that at population level inequalities in health are persistent and stubborn to shift; the lesson of the past 40 or so years is that will not reduce unless we actively focus on them.  Second, that to shift them we need a multifactorial approach, across government and through the NHS. Third, it also sends a warning: it is all too easy to lose focus, and when you do inequalities in health are likely to widen. Our view of the coalition government’s policy on inequalities in health is that it had little focus, ambition, reach or pragmatism. Since then, in the NHS the approach has been to focus narrowly on important but specific issues around diversity and equality, particularly in its own workforce; while at cross-government level it is hard to discern any coherent and systematic approach to health inequalities at all. In fact there has been no country-level strategy on health inequalities in England since 2008, and the title of this, Health inequalities: progress and next steps, belies its content – it is really an evolution of the 2003 strategy, not a new one. Fourth, that there are significant time-lags in effect, and we need to keep examining the past so that it can be a guide to the future. It is tempting, and understandable, for those in government, those holding the executive and government departments to account (parliamentary committees and the National Audit Office), other political parties and commentators to judge success or failure too early. What the Barr study shows is that when it comes to assessing the impact of policies on inequalities in health we need to take the long view, and we need to value looking back as well as towards the future. Indeed, another important study tracking premature mortality between 1965 and 2015 warns us that the gap in premature death rates in younger people between north and south has recently widened in younger people, reversing long-run trends.

To conclude, we now have the benefit of important new information and analysis which can help us step up on policy and action – both in the NHS and wider government – on inequalities in health. Part of that must be to take stock and to learn the lessons of the past before inventing the future. It’s not just the current government that needs to reflect on this; our assessment of the recent manifestos was not encouraging.

When we plan for the future, perhaps we should bear in mind the words of Aldous Huxley, author of Brave new world, ‘That men do not learn very much from the lessons of history is the most important of all the lessons that history has to teach.’