Published in Tribune 2 March 2007

Suresh Pushpananthan argues that public health and preventative measures should be given greater priority under a new Prime Minister.

Since the Black Report was published in 1981 health inequalities have stubbornly refused to shift. The fate of the Black report was representative of the Tories’ commitment to inequality. It was commissioned by a Labour government in its death throes, delivered to a Conservative one that cared little for the notion of inequality and even less for Black’s costly recommendations.

Since 1997, the Labour government has made substantial efforts to increase the attention given to health inequalities as part of wider health policies. The health of the population as a whole has improved since 1997, but wealthier people have benefited more than poorer people. A boy born today into the lowest social class in this country is still likely to die nine years before a boy born into the highest social class. A resident of Kensington can expect to live approximately 11 years more if a man, and 9 years more if a woman, than their counterparts in central Glasgow.

In 1997, Frank Dobson commissioned an updated review of health inequalities. Sir Donald Acheson, the former Chief Medical Officer, carried out an independent inquiry that found widespread evidence of persistent health inequalities. He recommended action in the NHS, on poverty, housing, education and employment.

Wider determinants of health such as education, employment and financial status play a more important role than health policies. The government’s 2003 report, Tackling Health Inequalities: A Programme of Action, supported existing initiatives designed to improve health and reduce the health gap. These included targeted action in the areas of education, welfare to work programmes, housing and urban regeneration initiatives.

In reality, it is too early to fully assess the impact of the health policies of the last ten years. There has certainly been some improvement in life expectancy and infant mortality. It is unclear how much of this is due to reduction in poverty and how much to effective health policies.

The huge cash injection over the last few years has undoubtedly improved healthcare provision. Tackling waiting lists is important for the poor who often linger on them longer than the rich who can afford the private fees necessary to jump to the front. However, the government have concentrated their efforts far too much on hospital care which is not the most sensible way to address inequality. A stronger public health agenda is required. It is surely far better to prevent illness than to treat it once it has ravaged someone’s life. It is also more cost effective to do so.

Poor people smoke and drink the most, and eat the worst. Britain suffers a relatively high incidence of heart disease and smoking-related illnesses such as cancer; they are concentrated among the poor, who are more likely to get them and more likely to die if they do. The death rate from heart disease in people under 65 is almost three times higher in Manchester than in well-heeled Richmond, Surrey. An unskilled man under 65 is four times more likely to die from lung cancer than his professional counterpart.

Smoking is now concentrated among lower social classes. For example, 42% of male unskilled workers smoke, compared with 15% of professional males. As people get fatter, another class divide is opening up. Some 28% of women in the bottom social class are obese – twice the rate among those in the top class. Action is needed now on these key threats or the financial and population implications will be disastrous for the NHS as it seeks to manage the failure to prevent the onset of ill-health. The ban on smoking in public places is a good start, but we should also increase the age at which cigarettes can be bought to eighteen.

The political returns from investments in public health are difficult to measure, and take time to materialise. Voters would rather hear about slashed waiting lists than about the number of people who are taking more exercise. The government needs to be bolder in taking the steps that are necessary.

Although the NHS is largely free at the point of use, there continues a system of charging for drugs, eye tests and dental services amongst others. Those who are deterred from taking their medication by the cost of prescription charges are those most in need. If the NHS is to play it’s part in reducing health inequalities these disincentives must be minimised. The cost of travel for treatment is going to become more important as specialist services are concentrated in fewer locations under the proposed reconfiguration plans. Increasing travel costs will only exaggerate the malicious effects of health inequalities.

In addition, the government’s choice agenda is likely to further widen such inequalities. The Choose & Book policy will benefit the middle classes disproportionately as the more articulate are able to elbow their way to better and quicker treatment. I have yet to see a patient in my outpatient clinic, through the new Choose & Book system, that is not a well educated, middle class person.

The government must show that it is as committed to tackling health inequalities as it has been to tackling waiting lists. The jury is still out on how far this commitment is serious and sustainable, or whether concerns about the state of hospital services will continue to monopolise Ministers’ time. Successive governments have failed to shift the balance away from short-term imperatives and the NHS has remained a ‘sickness service’ for too long. A long-term, sustainable public health agenda aimed at preventing illness rather than treating it is required. For a Chancellor that is sensitive to accusations that the government has pandered to the middle classes and done too little for the poor, such dramatic inequalities should be viewed as an opportunity to make his mark as Prime Minister.

Recommendations

The Choice agenda within the NHS must be redesigned to minimise health inequalities rather than widen them. If the government is to keep the flawed Choose & Book system it should insist on all GPs offering choice, not just the 35% of practices serving the better off.

Increased financial assistance with travel costs for those using distant hospital facilities. Comprehensive bus services must be provided to the new regional ‘super-hospitals’ that will be created under reconfiguration plans.

Increase the number of school nurses as promised in the government’s 2004 Choosing Health document. Health inequalities are determined from childhood. Healthy lifestyles need to be taught in schools.

Food and drink served in schools must meet strict nutritional standards. All junk food to be banned from schools.

Increase the age at which cigarettes can be bought to eighteen.

Suresh Pushpananthan is a specialist registrar neurosurgeon, lecturer in neurosurgery and a member of the Central Council of the Socialist Health Association

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