Sunday, 31 October 2010

GUEST POST: Health inequalities in the UK – our most pressing problem

This is a Guest Post by Rachit Buch, and is an edited version of an article published originally by The Vibe.

The burning issue

On Thursday the British Medical Association held a debate on Health Inequalities. Professor Sir Ian Gilmore, Professor Sir Michael Marmot and Secretary of State for Health Andrew Lansley MP were members of the distinguished panel. They discussed the most pressing contemporary problem for British society – why there is such a gap between the health of different sections of our society and what can be done about it.

Why is this society’s most pressing problem? Professor Marmot has the answers to this. The evidence he has helped to collect shows a 7 year gap in life expectancy and a 19 year gap in healthy life expectancy from lowest to highest socioeconomic group. Education, housing, alcohol-related and obesity-related harm and numerous other social factors cause this gap – meaning that in some meaningful way, other important social problems are in reality also health inequality problems.

Take the economy as an example. Professor Marmot's estimates show that approximately 2.5 million life years would be gained if everyone had the life expectancy of the best-off and that the economic cost of this gap is £31-33 billion per year. Granted, as he acknowledged, these figures come close to back of the envelope calculations. But the numbers are staggering and no-one has any evidence to fairly suggest that they are significant overestimates.

Improving health inequalities (by which I mean bringing the health of lower socioeconomic groups to levels achieved by higher groups) would go some way to meeting other major challenges we face. As Professor Gilmore noted, the health agenda fits with the environmental agenda in encouraging walking, cycling and moderating meat consumption. Increasing access to work would also improve the health gap, which would benefit the economy. And fundamentally, being alive is a necessary condition of doing anything.

Given this importance, is our failure to make progress the result of a lack of will? It seems not – recent Governments have placed reducing health inequalities high up the agenda. So is it a lack of know-how? The answer to this is a classic, academic yes-no. There is evidence of policies that can reduce the gap in health achievement but with such a broad scope, what politicians have struggled with is how to implement changes that are integrated and mutually enhancing across the
spectrum of Government departments. A sure-fire way of achieving this is yet to be discovered.

A lack of will is certainly not evident in Andrew Lansley's rhetoric. Having met with Professor Marmot whilst in opposition, Mr Lansley is aware of the gravity of this problem. He also conveys a genuine desire to tackle the problem and has a grasp of how to do so. These include working with local authorities and the third sector to develop local strategies, as opposed to mandating changes from the centre which often creates antagonism.

So are we to expect a revolution in health inequalities, with real improvements? It seems that to do so would be a little over-optimistic. The fundamental problem with Mr Lansley's approach is that, despite the cross-governmental work on health inequalities and public health, the actual policies delivered by his Party may well not support a reduction in health inequalities.

Mr Lansley believes in working in partnership with industry to achieve better health (though he excludes the tobacco industry form this). But it remains to be seen whether allowing food manufacturers effectively to pay to avoid laws restricting junk food with contributions to Government public health programmes is helpful. As someone who seems to be signed up to Thaler and Sunstein's Nudge movement, one would have thought Mr Lansley would believe that making the bad effects of poor nutrition instantly visible, rather than allowing them to manifest themselves as a pain in the chest and a tingling in the left arm 25 years later, was an indispensible tool.

Handing over responsibility for public health to local authorities at a time when councils are radically reducing their expenditure would seem to be another example of a lack of 'joined-up thinking.'

In Professor Marmot's ideal world, every Government policy would have to pass through a 'fairness filter' to see whether it is likely to decrease health inequalities before it is passed. Mr Lansley solemnly nodded his head at this remark but will make no attempt to work towards it. Though an actual fairness filter may be an unreachable goal, a better approach is needed. Now that health inequalities are on the agenda we cannot allow Government to talk about them without working on them across the board.

Professor Marmot talked about working on 'the causes of the causes.' Treating the health problems leading to early morbidity and mortality is not enough. This means a systematic attempt to decrease social exclusion, improve social cohesion through strong public provision of education, training and employment opportunities, aim for rehabilitation in criminal justice rather than marginalisation, re-instate the voice of the disappointed and apathetic majority into the public sphere through democratic reforms and devote more resources to evidence-based, proactive public health improvement rather than reactive illness management.

This may sound like a left-wing agenda, unachievable because of the impact of business interests and political inertia. If it was, then it would not be a tenable, and arguably fair, approach to reform. But it isn't. Humans tend to believe that whatever is currently the case always was the case and always will be. This mindset is the reason why we think of this approach as a left-wing one.

To make real advances, rather than making the case in the face of opposition from the business community’s ‘wealth creation agenda,’ we need to make this the arena within which differing interests compete. Currently, policy is directed towards creating economic growth – specifically, as measured by GDP. Business advocates and social inequalities campaigners argue that they are best placed to achieve this goal – vying for politicians' favour. As long as the social and cultural ties of politicians with business interests remain so close, there will only be one winner.

But instead, we should accept that for many countries this period of wealth enhancement has had its day. What we need now is for the best possible mental and physical health to be made achievable for the whole population, so that everyone can make use of our material wealth in ways which they feel will improve their lives. And big business can still compete for its own interests, as can trade unions, environmental activists and anyone with a bright idea and a loudspeaker/blog. But there needs to be a public debate as to how they can achieve this goal; how they are best placed to answer this, the burning question of our times.