Prevention and the reduction of health inequalities

The secretary of state for health recently announced the establishment of six “modernisation action teams” to help develop a national plan for a national health service.¹ The government has committed itself to improving public health and reducing inequalities in health. The decision to set up a “modernisation action team” on prevention and inequality is consistent with these goals. It is not clear, however, what this team is expected to do that is different from the analysis and recommendations contained in various recent government reports.^2–7 Saving Lives: Our Healthier Nation said its aim was “to improve the health of everyone, and the health of the worst off in particular.”³ It acknowledged the role of social, economic, and environmental factors in influencing population health and inequalities in health but did not confine itself to non-NHS initiatives to improve population health. The Acheson inquiry gave careful consideration to recent trends in, possible causal models for, and policies to reduce inequalities in health and made 39 policy recommendations, three of them relating to the NHS.⁶ So attention has recently been given to the role of the NHS in promoting public health and reducing inequalities in health.⁸,⁹ What will this action team do that has not already been done fairly recently? Does the government think that all these reports were a waste of time or have failed, or that the situation has changed radically since they were published?

Summary points

• The major drivers of health and the distribution of health lie outside the health service, so this plan should not confine itself to actions that could be taken by the NHS

• The government should review progress in implementing the Acheson report on inequalities and the public health white paper

• Some of the extra resources should be spent in partnership with organisations outside the NHS

• The government should acknowledge the tension that exists between overall health gain and reducing inequalities

• The priorities of the Acheson report should be acted on

Scope of the action team

The Department of Health has described this team as covering “prevention—tackling inequalities and focusing the health system on its contribution to tackling the causes of avoidable ill-health.” It also says that all the teams have a remit “to address variations in performance and standards across the care system as a major contribution to tackling health inequalities.” Both these statements could be taken to suggest that the scope of the prevention and inequality team might be confined to the role of the NHS. The prime minister said in the House of Commons in relation to this action team: “There is the challenge on prevention: to balance spending on tackling the causes of ill-health with treating illness; to develop a more systematic approach to treating people at risk from chronic diseases; and to persuade more people to play their part in achieving better health by adopting a more healthy life style.”¹⁰ This implies giving priority to the detection and treatment of people at known and proximate risk of killers such as cancer or heart disease, and that there will be further attempts to change individual behaviours by exhortation.

It would be disappointing if this action team was confined to this sort of agenda. Though the NHS has a role in promoting health, preventing disease, and ameliorating the health damage caused by disadvantage, most of the major drivers of population health and of the distribution of health lie outside the NHS.¹¹ Health ministers have acknowledged the importance of air pollution, unemployment, crime and disorder, poor housing, poverty, limited educational achievement, the general environment, and other forms of social exclusion. These influences on health are only rarely under the control of the doctors, nurses, or managers who are described as being the key architects in drawing up a national plan for a new NHS. This suggests that the action team should focus upstream on the causes of poor health and inequalities in health (what is pushing people into the river), as well as downstream at the behavioural or other risk factors for major killers (pulling drowning people out of the river—for example, by improving the treatment of myocardial infarctions in public places).

JEZ COULSON/INSIGHT

So what should this action team do?

Firstly, this action team should review progress on implementing the public health white papers and the Acheson report. It should establish the extent to which their policy recommendations have been acted on outside the health departments by other government departments, local government, and other key actors.

What should the action team do?

Review progress on public health reports

Ensure that extra resources go towards working in partnership with local government and other agencies

Develop strategy for dealing with tension between overall health gain and reduction of inequalities

Take forward the areas of highest priority given in the Acheson report

Secondly, the team should ensure that some of the extra resources announced for the NHS are directed to working in partnership with local government and other agencies. Many causes of population ill health, inequalities in health, and lack of uptake of healthy lifestyles lie not in individuals but in the social and physical environment. Rather than focusing exclusively on “at-risk people,” the government and healthcare system should also focus on the role of opportunity structures in local environments—for example, on the availability of safe play spaces for children, accessible and reasonably priced food, educational and employment opportunities, and housing built and maintained to tolerable standards.

Thirdly, it should develop a strategy for dealing with the tension between the goals of generating overall health gain and the reduction of inequalities. This involves recognising that both poor and rich people are living longer, but the healthy life expectancy of rich people is increasing faster than that of poor people. Health promotion strategies focusing on individual health behaviours such as smoking, diet, and exercise are more commonly and quickly taken up by those with better personal and local resources. Thus although there has been an overall reduction in the prevalence of smoking in Britain, there has been a widening gap between social classes in the prevalence of smoking and smoking related diseases. The health gain to be obtained from any given input depends on the capacity of the target population group to benefit. The capacity to benefit from individualised risk management or health education may be least among more disadvantaged people, and therefore the costs (to them and others) of improving their health may be greater than the costs of improving the health of relatively advantaged people. The action team needs to deal with this problem explicitly.

Fourthly, the team should take forward the three areas given highest priority by the Acheson report⁶:

• “All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities.” The team needs to establish appropriate ways of measuring and monitoring the impact on health inequalities of activities in a range of sectors (transport, housing, education, taxation, and the benefits system, as well as the healthcare system). Evidence based medicine is now well established in this country, but evidence based policymaking is not. It is important that robust methods are developed for evaluating the impact of policies, programmes, and projects on the health of the population and of different subgroups, since such activities might damage health rather than promote health and may have different effects on different groups. Impact on health is not the same as impact on health inequalities; some interventions might generate an overall health benefit but may either increase social inequalities in health or damage the health of some population groups, and we should be monitoring this.

• “A high priority should be given to the health of families with children.” Most of the recent analyses of determinants of population health, and of inequalities in health, show the likely importance of early life influences on health and the lifetime cumulative effect of experiences and exposures. Focusing on families with children will not only help with immediate problems of maternal and child health but may help reduce the longer term risks of adult chronic illnesses such as bronchitis and coronary heart disease.

• “Further steps should be taken to reduce income inequalities and improve living standards of poor households.” Inequalities in health are ultimately caused by social inequalities (in income, wealth, education, and other life chances). If we seriously want to try to reduce inequalities in health we should try to reduce the structured social inequalities which create them, rather than focusing on the immediate short term risks that are manifestations of an unequal society (such as obesity, high cholesterol, poor lung function consequent on many years' smoking, or early and unplanned pregnancy).

This is the second of seven articles