Population health & reduction of health inequalities
The UK has the longest and strongest tradition of research on the social determinants of health and health inequalities for any country, more government papers and reports, and more policy. Yet British governments have struggled to reduce inequalities in health.
What policies implemented by a Labour government would be effective in reducing health inequalities?
[References appear at the end of this policy brief.]
Throughout the year of Labour government, 1997-2010 progress was made in reducing inequalities because the government pursued a comprehensive programme. The 1999 Reducing health inequalities: an action report adopted many of the recommendations from the 1998 Independent Inquiry into Inequalities in Health. Government economic and social policies included a national minimum wage, higher benefits and pensions, increased spending on education, housing, health and urban regeneration, the ‘Sure Start’ programme, and Health Action Zones.
Targets for health inequalities were set in 2001 with the goal of narrowing differences in life expectancy among geographic areas and the differences in infant mortality across social classes. In 2002, the government published the Cross-Cutting Review of Health Inequalities, then Tackling health inequalities: a Programme for Action in 2003 (which had greater emphasis on changing health-related behaviour), in 2009 Tackling Health Inequalities: 10 Years On, and in 2010 the Marmot Review, Fair Society Healthy Lives.
The most recent research on inequalities in health in England assessed trends in life expectancy before the 2003 Programme for Action (1983-2003), during the implementation of the programme, and in the Coalition/Conservative era. The analysis shows clearly that ‘the English health inequalities strategy were associated with a decline in geographical inequalities in life expectancy, reversing a previous increasing trend.
Since the strategy ended, again inequalities have started to increase. There has been an alarming increase in the North-South divide in death rates for adults aged 25-44. Growing body of evidence verifies the impact of austerity on population health since 2010, including a shocking rise in infant mortality amongst the lowest social class. The evidence indicates tens of thousands of excess deaths among the elderly, the end of a century long rise in life expectancy, and rising numbers of suicides.
Surveys show that the British public are consistently concerned about health, the National Health Service and social care. The Labour Party could use new research findings on the damage to population health caused by inequality and austerity to call for progressive economic and social policies that support population health and reduce inequalities.
Progressive taxation and reductions in income and wealth inequality are not ‘the politics of envy’ but the politics of improved health and well-being for the whole population. Progressives need to stress rising death rates for babies in poor families and among the frail elderly.
Political discussion should include the immorality of the fifth largest economy in the world failing to protect the health of not only the most vulnerable, but all citizens and residents. The Conservatives, faced with evidence that health inequalities are widening and health gains being reversed, point to international rankings of health services that place the NHS at the top. It is not just health services that shape the health of the public.
The NHS requires greater resources, and this should not be separated from most important measures to improve public health and well-being, economic and social policies that reduce both poverty and inequality.
Progressive economic and social policies provide the resources for increased investment in health and social care and by reducing poverty and inequality have direct benefits on the health of the whole population.
The top policy proposals from a survey of public health experts are those that reduce poverty and inequality and ensure quality of life for everyone. The impact of reducing inequalities outweighs changes in lifestyle and expenditure more on health services. This conclusion reflects the consensus among experts that it is the structural social determinants of health that matter the most. These proposals are:
- Progressive systems of taxation, benefits, pensions and tax credits that provide greater support for people at the lower end of the social gradient and do more to reduce inequalities in wealth.
- Development and implementation of a minimum income for healthy a life including an increase in the minimum wage.
- More resources in support for vulnerable populations, by providing better homeless services, mental health services and other social care.
- More resources for active labour market programmes to reduce long-term unemployment and for in primary care health services in deprived areas.
- Support an enhanced home building programme including in decent social housing to bring down housing costs.
- Reduce speeds in urban areas, starting with the poorest areas, especially to protect children and the elderly.
- Increase social protection for those on the lowest incomes and provide more flexible income and welfare support for those moving in and out of work.
- Increase the proportion of government expenditure allocated to the early years of life and insure that this expenditure is focused progressively across the income distribution.
Mackenbach JP. Has the English strategy to reduce health inequalities failed? Social Science & Medicine 2010;71(7):1249-53.
Barr B, Higgerson J, Whitehead M. Investigating the impact of the English health inequalities strategy: time trend analysis. BMJ 2017; 358:j3310.
Buchan I, Kontopantelis E, Sperrin M, Chandola T, Doran T. North-South disparities in English mortality 1965-2015: longitudinal population study. Journal of Epidemiology and Community Health 2017;doi:10.1136/jech-201-209195.
Taylor-Robinson D, Barr B. Death rate now rising in UK's poorest infants. BMJ 2017;357:j2258.
Green M, Dorling D, Minton J. The geography of a rapid rise in elderly mortality in England and Wales, 2014-15. Health & place 2017;44:77-85.
Institute for Health Equity. Life expectancy rises 'grinding to halt'. http://www.ucl.ac.uk/iehc/iehc-news/michael-marmot-life-expectancy 2017
Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler D. Suicides associated with the 2008-10 economic recession in England: time trend analysis. BMJ 2012;345.
Smith KE, Kandlik Eltanani M. What kinds of policies to reduce health inequalities in the UK do researchers support? Journal of Public Health 2015;37(1):6-17.
Smith KE, Bambra C, Hill SE. Health Inequalities: Critical Perspectives: Oxford University Press, 2016.
Kate Pickett is Professor of Epidemiology in the Department of Health Sciences at the University of York, and is the University's Research Champion for Justice and Equality.
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