Report by Daisy Hayden, of the Commission for Patient & Public Involvement in Health
This conference offered a fascinating insight into current trends in inequalities in health, and current and previous attempts to address the wider determinants of health, and reduce inequalities in health, particularly those related to income, social class, and geography.
The Chair, John Lipetz gave the conference a local context, emphasising the effects on health of factory workers during the industrial revolution.
gave an outline of the current situation and policies regarding health inequalities. She acknowledged there was a lot of work still to do. She wants to translate aspirational values into action, resulting in changes such as parents’ occupation is no longer being the main determinant of your health or life chances.
Presentation main points:
Questions:
how to help parents of disabled children, who are trapped in poverty. Delegate
invited to write to Minister who will investigate.
Exemptions to smoke free premises will lead to widening inequalities. “We may
be able to go further around smoking exemption.”
Health Living Networks, need support for older people, inter-generational and
GP input
There is concern around who provides healthcare – people want good quality NHS
services, not necessarily enhancing profits of private companies.
Better jobs and training needed – not necessarily better to be in work when
you have low pay and poor conditions.
There should be more interagency cooperation, Minister: Don’t know why there
are so many problems.
Current consultation on health and social care integration, chance to people
to give their views and improve interagency working.
Defined inequalities in health as:
“Unfair or unjust differences in health determinants or outcomes within or between defined populations”
Plus – there difference between equity (access to services and resources etc).
Equality – from each according to his ability, to each according to his needs.
Black Report – 25 years ago Government attempted to suppress it on publication and Health Divide report, seven years later.
1980 – As editor of Radical Community Medicine (became Critical Public Health) speaker photocopied and reproduced introduction and findings.
Black report asked are the differences
Local reports in Sheffield at Ward level – access to health, life chances were most important
Other approaches – Psychosocial epidemiology, life course epidemiology, early life experience also valid, developed more recently.
Policy approaches
1980s - “Trickle-down” effect from rich,
Major Govt – variations in rates. Narrow focus e.g NHS
Blair I – Inequalities bad –implemented Health Action Zones, Healthy Living Centres;
Blair II – Retreat from Welfare. Neo-liberal market principles, Evidence-based e.g. “What works”, shift to right.
In capitalism – unequal distribution of resources is necessary.
Government should be honest and say what levels of inequality are acceptable
Social Democratic Model – Managed capitalism.
Health Ministers: Hazel Blears, 3 years ago. Radical speeches but little action.
Dobson, Jowell, little development
New labour is a serious threat to welfare state and public health.
Income inequalities have widened between1980 – 2003.
Inequalities in life expectancy and infant mortality have also widened
Report published 11 August 2005 – no links, mentioned at bottom of Department of Health News Release on “health trainers”, when the whole report is available on line.
Causes of death – mortality rates have decreased for many conditions, but inequalities have not reduced.
Most health policies have been “downstream” ie after people have become ill. Need upstream policies to tackle social forces such as economy.
Some are mid-downstream – e.g. Sure Start.
Choosing Health and other recent initiatives - don’t believe in universal approach, but targeting. Should be called Destroying not Choosing Health. Choosing Health dismissed as “individualistic gimmickry”.
Privatisation, commercialisation of NHS and welfare systems is continuing. Patients do care who provides their services, don’t want to contribute to profits of Evercare and other providers.
People don’t want to travel for shorter waiting lists, they want good quality local, accessible services.
Other current initiatives:
See Public Money. Aug 05, 237-343.
Values. Macro –economics, global economy.
John Hewetson, 1913- 1990: Ill Health, Poverty and the State. Freedom Press. Inequalities are marked by social class. Banned in 1945:
“Achievement of full health requires a change in the system of production”.
Questions:
· But what practical solutions are there in the real world, within the capitalist system.
- Experience of GPs in Liverpool 8 – things have improved.
- Hospitals are moving older people to private nursing homes
- Need change in values, everyone should be valued. We can make incremental changes. Social democracy is a “wonderful sticking plaster for addressing wider determinants of ill-health.”
- Western countries such as Norway, and poorer countries such as Costa Rica, Cuba and the Indian state of Kerala have made significant progress, and are real welfare states.
- People should be enabled to have more control over their lives.
Wanless economic approach not helpful – social investment state. ‘Social capital’ is a meaningless phrase.
- Need more education around health, but national health promotion bodies such as Health Education Authority abolished. No national health promotion body, whereas most European countries have these.
- A. Voluntary contributions to care not recognised by Government, at the same time seen as an excuse for rolling back state facilities. Public sector should improve community development approaches.
Nothing has changed in 25 years since the Black Report. The Department of Health did try and suppress the update – BBC were the only agency to pick up on the Findings. The press release of 11 August 2005 did not link to the document. [Headline: Sites for first health trainers announced as report shows progress on reducing health inequalities].
The release mentions the status report, and includes a quote from Michael Marmot, one of the authors, but doesn’t link or reference it.
In fact differences in life expectancy and infant mortality between working class and middle class people have widened. This should be seen as a major abuse of human rights.
Underlying factor is income inequality, which rose sharply during the Thatcher Government, then a slight decline, then has continued steadily upwards since 1997.
There have been positive tax and benefits reforms since 1997. Reduction from one in four to one in five children in poverty.
What political action is appropriate?
What is driving health inequalities?
Psychosocial factors are important. These are the pathways through which socio-economic conditions are expressed or manifested. Eg feelings of not being valued, respected, and looked down upon. Manifests in health related behaviour such as addiction and risk of dependence, stress, worse health outcomes, violence.
International comparisons show homicide rates are higher in more unequal countries. Improvements in health will lead to reductions in violent crime and homicide.
Social gradient also influences outcomes in other areas such as education – eg Sweden and Canada have made significant progress. In the US there is less social mobility, the most significant determinant of your life chances is your parents’ (especially father’s) occupation.
Way to improve people’s health fastest is to reduce inequalities, because the higher strata are healthier anyway. Rich countries are not necessarily healthier – e.g. Greece has narrower health inequalities.
Income is a good indicator of class, manifests itself as perceived differences in status.
More egalitarian societies are healthier. Where there is more spending on health there is less perceived inequality, and narrower income distribution.
International comparisons show New Orleans has widest differences in life expectancy, and lowest health spending, and Melbourne is at the other end of the scale.
Meta analysis of 169 papers – to investigate whether there is a correlation between income and health.
“Inequality is the greater obstacle to human harmony”.
Evidence could be borne out by current situation in Iraq, and Louisiana. There is inequality in levels of violence between different states of the US. Theory that the quality of social relations, how you are perceived by other members of society, and status anxiety are all important factors here.
Differences in levels of trust, sense of community, involvement in local (or other) community all related to inequality.
Robert Puttnam has studied involvement in 20 regions of Italy, and found that there is more involvement, society is more egalitarian, and income inequalities have reduced in the last 20 years.
Violence is triggered by people feeling looked down on, disrespected, and denied access to workplace, and “markers of social respect”. More marked in materialistic societies.
Plus more social isolation affects your immune system – one experimental study showed people caught more colds the more socially isolated they were.
Psychosocial risk factors are influential throughout life
Most common stressors: “Tasks that include social evaluative threats”. Jeopardy of self-esteem, regardless of your needs.
Black report – Govt said it had “too many recommendations, not enough prioritising”.
Need quick wins, reports was seen as too ambitious.
Sweden adopted many of the recommendations.
There have been developments since 1997, such as Sure Start (Headstart in the US)
(Though it has been subject to criticism recently. See What Affects health – Early Life and Social Support).
Effects of inequalities are long term
Post war prevention of mass unemployment, need to pay that generation back
1981 – Attempted to pass a resolution at Brighton Labour Party Conference, but told that reference to Beveridge evils – Want, Ignorance, Idleness, Squalor and Disease was old fashioned.
Previous focus was universal, but now more targeted – Population-based approach to tackling teen pregnancy, need new approach to human relations and children, rather than narrow “at risk” group approach. But at the same time perhaps you should also focus on sectors of the population who are more at risk of ill health and have worse life chances, such as children leaving care.
Other innovative approaches include local Fire Services initiatives – increased role in accident prevention, halving deaths due to installation of fire alarms. Firefighters are working with young people, acting as role models, stations as Health Living Centres. Local Government needs more of a role in improving wellbeing.
last updated 22/07/08