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

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?


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.