Health Inequalities and the New Public Health Agenda

1. Health Inequalities and the New Public Health Agenda

2. Structure • Who is Affected: • Social gradient • Access & The Inverse Care Law • Black Report • Acheson Report • New Labour Initiatives • Coalition Initiatives

3. Who is affected? • Ethnicity: • More likely to report ill-health and that ill-health starts at a younger age than White British • Age: • Two thirds of the population with a limiting long-term illness or disability are aged 55 and over. • Gender: • Women live longer. However, women in the higher socio-economic classes die later and experience less disease and disability than lower class women • Class: • Generally measured on occupation although can be measured on housing tenure, car ownership, income, education level

4. Social Gradient

5. Is Access the problem? Julian Tudor Hart: The ‘Inverse care law’ “The availability of good medical care tends to vary inversely with the need for it in the population served” (Lancet 1971;I:405-412)

6. Thirty years of the ‘inverse care law’ ‘Socio-economically deprived patients are thought more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority’ (Pell et al, BMJ, vol 320 Jan 2000, p15-19)

7. Reasons for the ‘inverse care law’ • Geographical and regional inequalities – concentration of health care facilities in middle class areas – something continued by the NHS • Demand factors – middle class patients were better at accessing services and doctors and medical professionals discriminated in their favour

8. Need to ‘refocus upstream’ There I am standing by the shore of a swiftly-flowing river, and I hear the sound of a drowning man. So I jump into the river, put my arm around him, pull him to the shore and apply artificial respiration. Just when he begins to breathe, another cry for help. So back into the river again: reaching, pulling, applying, breathing – and then another yell. Again and again, without end goes the sequence. You know, I am so busy jumping in, pulling them to the shore and applying artificial respiration, that I have no time to see who is upstream pushing them all in. (Zola, Social Science and Medicine 1973: 677-689)

9. The Black Report 1980 • 3 X as many social class V as opposed to class I infants die in first year of life • 2 X as many children die by age of 14 • Adults in social class V were nearly twice as likely to die by the age of 64 compared to those in social class I • Health improved but inequalities widened

10. Registrar General’s social class Social ClassClassification I Professional (e.g. account. lawyer) II Intermediate (e.g. manager, nurse) IIIN Skilled non-manual (e.g. secretary) IIIM Skilled manual (e.g. carpenter) IV Partly skilled (e.g. agricultural worker) V Unskilled (e.g. cleaner, labourers) (Townsend and Davidson 1990: 40)

11. What explanations did the Black Report consider? • Artefact - statistical quirk - The relationship is somehow an artefact of measurement systems used • Natural or social selection - This implies that the sickly will slide down the social scale while the robust will have a greater chance of social advancement • Cultural or Behavioural - values and behaviour of members of a social group affect a group’s health status, rather than its structural position • Materialist - the material and structural position of member of a social group directly affects their health

12. Findings and recommendations • The materialist explanation had the most merit. • Material advantage and disadvantage, in the context of ‘relative poverty’ was put forward as the most significant explanation of the observed inequalities • Improve access to health services. Combat material disadvantage. • Report dismissed and buried by the incoming Conservative government

13. A ‘Frosty’ Reception Patrick Jenkin, Conservative Secretary of State for Health ‘…quite unrealistic in present or any foreseeable economic circumstances, quite apart from any judgement that may be formed of the effectiveness of such expenditure in dealing with the problems identified’ (Townsend and Davidson, 1990. p.4)

14. Behavioural/cultural Explanations • Social position determines health through social differences in health-damaging or health-promoting behaviours • E.g. smoking, diet, excessive consumption of alcohol and lack of exercise • Not determined by the wider society but by differences in knowledge or ‘free’ choices • Dominant medical and government approach

15. Do health-related behaviours account for health inequalities? ‘If circumstances are good, healthy behaviour appears to have a strong influence upon health. If they are bad behaviours make rather little difference’ (Blaxter 1990: 216)

16. Materialist Explanations • Social position determines health through social differences in the material circumstances of life • Structure versus agency: the ways in which material disadvantage and inequality, and need to earn a living expose people to risk and limit ‘healthy choices’ • Housing income, safe working environment – caught between rock and a hard place • Operates throughout the lifecycle • Across the class gradient

17. Social Determinants of Health Social structure operates via: • Direct material effects • e.g. low income, risky and stressful work, pollution, et - Psychosocial effects of relative poverty • coping mechanisms, e.g. smoking • mind-body pathways, e.g. raised blood pressure

18. Acheson Report (1998) • Health inequalities widened further still in the 1980s • Widening of concern from class inequalities to include gender and ethnicity based inequalities in health • Election of Labour Government resulted in an independent enquiry chaired by Sir Donald Acheson with the task of reviewing evidence on health inequalities and identifying areas of policy which could be used to reduce them

19. The 1998 Independent Inquiry into Inequalities in Health (Acheson) • Found the Black Report was correct and endorses its materialist approach • Inequalities in health persist, however measured, and taking account of gender and ethnicity too. • These inequalities can be identified at all stages of the life course from pregnancy to old age • New Labour targets health inequalities as a result. • Fearful of being the ‘nanny state’

20. New Labour’s 1998 White Paper, ‘Saving Lives: our healthier nation’ • Two Key aims: • To improve the health of the population as a whole by increasing the length of people’s lives & the number of years people spend free from illness • To improve the health of the worst off in society and to narrow the health gap

21. White Paper ‘Choosing Health: making healthier choices easier’ (2004) • Continues theme of ‘tackling inequalities in health’ • Emphasis now esp. on individual consumerism: ‘Choice’ and ‘personalisation’ • Plus joint working between local agencies rather than tackling wider economic causes • Labour believes that it can target health inequalities without targeting inequalities as such

22. Coalition initiatives • The ‘Health Premium’: • “promote action to improve population-wide health and reduce health inequalities” • Health budget ‘ring fenced’ from cuts • But less money for reducing inequalities (down from 15% budget to 10%) • New duties proposed for NHS commissioning bodies to reduce health inequalities