Tackling inequalities in health
‘What greater inequality can there be than to die younger and to suffer more illness throughout your life as a result of where you live, what job you do and how much your parents earned.’ So said Yvette Cooper, Parliamentary Under Secretary of State for Public Health, launching the consultation paper Tackling Health Inequalities. Here, Tim Marsh examines this latest government initiative, together with the national health inequalities targets, and asks whether they are likely to be successful in reducing the health gap between rich and poor.

Background
National health inequalities targets
Target One
Target Two
Tackling Health Inequalities
What are the interventions?

Background
Health inequalities are the UK’s most visible public health challenge. The health of people in the more affluent areas of the country is among the best in the developed world, but the health of the most disadvantaged rivals the worst. Health inequalities are most marked in areas where deprivation is most acute. People living in poorer communities die younger and experience poorer physical and mental health throughout their life than those living in more affluent communities.

The evidence for the existence of inequalities in health can be traced back 250 years, but it was the now infamous Black Report,[footnote 1] commissioned by the Labour Government in 1979 and subsequently suppressed by the incumbent Conservative Government, which rekindled the debate about poor health and social class.The Black Report showed that whilst the health of the nation had generally improved since the 1950s, the health gains had not been shared equitably and that health inequalities were widening. This trend has continued, with health (along with income) inequalities widening dramatically throughout the 1980s and 1990s. During this time, even the semantics changed, with health ‘inequalities’ being renamed health ‘variations’.

The return to power of a Labour Government in 1997 brought health inequalities onto the political agenda once more. One of the Government’s first acts was to commission former Chief Medical Officer, Sir Donald Acheson, to carry out an Independent Inquiry into Inequalities in Health. The subsequent published report led to the development of a public health strategy, Saving Lives: our healthier nation, which presented the Government’s approach to tackling inequalities. It proposed four national targets to reduce deaths from heart disease, strokes, cancer and suicide and to reduce accidents. This in turn led to the publication of the National Health Service Plan which gave a commitment, for the first time ever, to the creation of local targets for reducing health inequalities, reinforced by two national inequalities targets.

Subsequently, we have seen the establishment of an Inequalities and Public Health Task Force, which will assist in forming the strategy to tackle health inequalities by advising on the development of the targets and reviewing existing Department of Health public health programmes.

In Summer 2001 we saw Treasury Minister, Andrew Smith, name health inequalities as one of the seven priorities for the initial cross-cutting reviews that will make up the 2002 Comprehensive Spending Review. [footnote 2] Finally, in August the consultative document, Tackling Health Inequalities, was published.

National health inequalities targets
‘In poorer communities the NHS now has a key role to play. By working in partnership with local people, local government and local organisations the NHS can make a huge contribution to narrowing health inequalities. And to focus the efforts of the NHS we will now set for the first time ever clear national targets to reduce those health inequalities.’ Alan Milburn, Secretary of State for Health, speaking at the Royal College of Physicians 28 February 2001

The most widely understood measures of health inequality are life expectancy and infant mortality, measured in relation to social class differences. The life expectancy gap between social class I and V is 9.5 years for men and 6.4 for women.[footnote 3] The other popular way to measure inequality is in geographical terms and this is the method the Government has chosen in setting its target for adult mortality.

Target One
Starting with health authorities, by 2010 to reduce by at least 10 per cent the gap between the quintile of areas with the lowest life expectancy at birth and the population as a whole.

Life expectancy is currently 2.2 years lower for males and 1.7 years lower for females in the worst 20 per cent of health authorities, although initiatives such as the Cancer Plan and the Coronary Heart Disease National Service Framework, anti-smoking measures and anti-poverty strategies such as neighbourhood renewal are expected to lead to improvements. This target was formulated before the proposed substantive changes to health authorities and it is, therefore, unclear how it will be affected by these.

The table below shows the standardised mortality rates (SMRs) for ten equal-sized geographical areas in terms of population (or deciles). SMRs which are greater than 100 indicate higher chances of mortality, all relative to the national average. The table demonstrates a continuing polarisation in mortality rates. People living in the best areas have an improving life expectancy, whilst those in the worst areas face a decline, to such an extent that by 1998, those in the worst areas were twice as likely to die by the age of 65 as those in the best areas.[footnote 4]

Target Two
Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between manual groups and the population as a whole.

Extrapolation by the Department of Health suggests that the national child under one mortality rate for all social classes (for births within marriage and joint registrations) is expected to fall for the first time below five deaths per thousand live births by 2006. The rate is currently 5.7 deaths per thousand. This would lead to there being a total of 3,000 fewer infant deaths between 1998 and 2010.

The purpose of this target is to galvanise action that improves the health of mothers and their children - starting with mothers. It is interesting to note that the target excludes ‘sole registrations’ – ie, births to lone parents (who as a group have the highest risk of poverty). This is apparently due to an anomaly in the data, although it does not make clear why the mother’s status at birth could not be taken into account. However, a commitment has been given to monitor trends among this group. As with Target One, this target will also be affected by the introduction of a new social class classification and it is not clear how it will be reformulated to take account of this.

Infant mortality may be an important health inequality indicator, but it is by no means the only one. There is a multitude of evidence linking child health and poverty. There is consistent positive correlation of adverse health outcomes, including death and a range of illnesses, parent-reported morbidity and factors associated with poor health. Studies have found differences in mortality rates across the age range in:

• infant mortality rates/sudden infant death syndrome;
• under 5s accidental deaths, particularly fires;
• age 5-9 accidental deaths;
• age 10-14 suicides and self-harm;
  
• age 15-18 accidental deaths and suicide.

And in morbidity:

• hospital admission rates for bacterial meningitis and accidents;
• dental caries;
• psycho-social morbidity;
• behavioural problems in younger children;
• primary care contact rates.

In birth weight:

• low birth weight rates;
• mean birth weight;
  
• birth weight by 500gm bands;
  
• percentage of births outside optimal bands;
  
• mean height attained at different ages.[footnote 5]

Different people will, of course, call for different targets. What we have been offered are very broad, which means that it will be difficult to identify particular interventions that have directly impacted on the targets. To be truly effective a headline target needs to be combined with a basket of more specific targets – something that the consultation sets out to address.

There are several other problems with setting targets of this kind. There can also be a tension between local and national targets as different inequalities may be more or less important at local levels. There is a fundamental incompatibility between improving averages and addressing inequalities; they are not synonymous. So the targets need to focus not just on bringing the worst off up to the average – because if the better off continue to improve at a faster rate than the average, then the gap will continue to widen. Because the targets have been set over such a long period it will be difficult to maintain ownership; a different government could use or discard targets as it thinks fit.

Tackling Health Inequalities
This consultation (in England only) is the most thorough official recognition of the fact that inequalities exist in all areas of health. It acknowledges that whilst the NHS clearly has an important role to play in reducing health inequalities, there are wider determinants of good health than just having good health services.

The consultation asks for opinions on three key questions:

The proposed six priority themes, together with any suggestions of other effective actions, of equal priority, that could become part of a wider national programme as this work develops. The consultation is particularly looking for local examples of good practice. The proposed themes are as follows:

• Reducing infant mortality and morbidity among families on low incomes, with a positive emphasis on the importance of maternal well-being and the early years to reducing health inequalities in later life.
  
  
• Improving the needs of children and young people, again with a view to reducing inequalities in later life. Both of these are very much in line with the Government’s stated aim of ending child poverty.
  
  
• Improving the responsiveness of local level NHS primary care services in order to reduce health inequalities.
  
  
• Promoting action against the big killers – coronary heart disease and cancer – mainly through changes in smoking and eating behaviour.
  
  
• Local level interventions in disadvantaged communities to co-ordinate action and encourage community members to contribute to the health inequality targets.
  
  
• Examining the types of action that can be taken to address the wider determinants of health inequalities – ie, a more holistic approach to addressing health inequality – particularly the impact of income on good health, although again the focus is on the poorest and most disadvantaged, without any mention of the wealthy.

The proposed systems and processes to support this work and the ways in which they can be strengthened further to support action to address health inequalities. The consulation asks:

• what more can be done to engage primary care trusts in improving health and reducing inequalities?
  
  
• what more can be done at both national and local level across government to co-ordinate, and maximise the impact of, initiatives that address health inequalities – ie, via the new local strategic partnerships?

The general approach proposed for the development of the basket of indicators. Both the national targets are to be reformulated – infant mortality when the new socio-economic classification is introduced; life expectancy when health authorities are reorganised. How will we be able to tell what actual progress has been made if the goalposts keep moving?

What are the interventions?
Throughout the consultation document, various current interventions are highlighted, designed to reduce the inequalities in health. There is even a companion document, From Vision to Reality, that is basically an audit of the various policies that should impact on health inequalities. Margaret Whitehead has identified four ways of grouping the policies:[footnote 6]

1. Strengthening individuals in disadvantaged communities
   These are interventions with a behavioural or empowerment focus, trying to build knowledge competency and skills to enable people to alter behaviour, cope better with stress, or take action to improve life circumstances. Examples include outreach programmes to reach hard-to-reach groups, including the Teenage Pregnancy Strategy and Sure Start.
   
   
2. Strengthening disadvantaged communities
   These are based on recognising the importance of community cohesion, attempting to facilitate collective action to reduce health hazards – for example, neighbourhood renewal strategies, community development, health action zones and healthy community colloboratives.
   
   
3. Improving provision and access to essential facilities and services
   Stimulating demand and improving the provision of services for the most disadvantaged and under-under-represented populations. This includes expanding the number of GPs and improvements in primary care services in deprived areas.
   
   
4. Encouraging macro-economic and social change
   This involves working across the whole population to address the prerequisites for health, such as ensuring adequate incomes, safe and fulfilling employment and a safe living environment. Examples include the Government’s pledge to end child poverty with its attendant increases in child benefits for children and mothers, the fuel poverty strategy, and education and employment programmes.

The consultation and the setting of national health inequality targets (something, despite their limitations, the public health lobby has campaigned for over many years) are very welcome. As is the intention that it will also inform the Government’s Cross-Cutting Spending Review on Health Inequalities. They do, however, only cover England and health inequalities cannot be solved unilaterally. There also remains some confusion as to whether the Government’s aim is to reduce inequalities or abolish poverty, because they are not synonymous.

Tim Marsh is Policy Officer at the United Kingdom Public Health Association

Footnotes
1. M Whitehead, P Townsend et al, Inequalities in Health, Penguin, 1992 [back to text]
2. HM Treasury Press Release, 25 June 2001 [back to text]
3. L Hattersley, 'Trends in Life Expectancy by Social Class: an update'. Health Statistics Quarterly 2, 1999, pp16-24 [back to text]
4. M Shaw, D Dorling, D Gordon and G Davey-Smith, 'Health and Poverty' in An End in Sight? Tackling child poverty in the UK, CPAG, 2001 [back to text]
5. N Spencer, Poverty and Child Health, Radcliffe Medical Press, 2000 [back to text]
6. See note 1 [back to text]

Poverty 110, Autumn 2001