nf0268: okay are we ready to start [3.1] okay so how can [0.2] inequalities in 
health [0.4] be tackled [2.4] so in this session we're going to look at [0.5] 
why tackle health inequalities [0.2] why tackle these er [1.0] unequal patterns 
of health that we've been looking at [0.2] very carefully over the last few 
weeks [1.6] so we're looking at why tackle them [0.9] then we're going to start 
to look at what the evidence says [1.0] about how health inequalities can be 
tackled [3.1] and then we're going to er start to look at [0.4] er [1.2] later 
on this morning [0.6] policies that are in place to tackle health inequalities 
[1.1] and to start to think about how effective [0.2] these policies are likely 
to be [0.6] er to reduce health inequalities [3.3] so [0.2] just to remind you 
[0.2] we've looked at [0.3] the four main explanations for inequalities in 
health [2.7] are they just an artefact of the way [0.2] the stastistics 
statistics are collected [0.6] are they due to social selection [0.3] are they 
[0.2] due to lifestyles and [0.2] behaviour [0.4] or are they due to material 
circumstances [1.5] oops [1.0] and that [1.2] probably wasn't a clever way to 
do 
that [1.8] and again [0.2] namex looked quite er thoroughly at the evidence 
that suggests [0.2] that er [1.7] the only explanation that can effectively [0.
3] explain [1.1] inequalities in health [0.3] is the fact that er [0.5] is the 
explanation related to poor material circumstances [1.9] culture and health 
behaviour on its own can only es-, explain about twenty to thirty per cent of 
the differences health differences between social groups [3.8] but [0.2] social 
and material circumstances er [0.7] in particular low income [0.4] er poor 
access to physical resources like housing [0.4] and the psychosocial stress of 
[0.2] er living with low income [0.5] er affects people's health both 
physically [0.3] and mentally [0.3] and shapes people's health behaviour [0.4] 
and we looked at how people's health behaviour [0.3] was sh-, er in in re-, how 
[0.3] was shaped by [0.3] in the area of er access to food and eating beha-, [0.
2] behaviour [0.4] and in relation to cigarette smoking so we looked at that 
last time we were in [5.1] okay so [1.3] why [0.3] should [0.3] health 
inequalities be a concern [0.5] of doctors really why are we 
teaching you this why [0.4] why is it considered important er that you study 
this [0.4] er other than the fact that [0.2] the General Medical Council said 
says that it's part of your curriculum [0.4] there are a number of reasons why 
er you need to [0.5] er [1.2] understand and be aware of how health 
inequalities can be tackled [0.8] i mean first of all because they have a 
profound effect on people's lives and have a profound effect [0.3] on the lives 
of the patients that you're going to be dealing with on a daily basis [0.6] and 
as Frank Dobson said in nineteen-ninety-seven [0.4] inequality in health is the 
worst inequality of all [0.8] there is no more serious inequality [0.3] than 
knowing that you'll die sooner because you're badly off [1.0] and i think that 
sums up very clearly [0.5] er [0.2] why [0.5] we should concern ourselves with 
this issue [1.5] so [0.8] inequalities in health are really [0.2] an issue of 
of natural justice [2.5] so continuing that [0.4] why else might we need to er 
[0.6] think about reducing health 
inequalities [0.5] well first of all we need [0.2] to [0.2] to do so because er 
health inequalities have substantial costs attached to them [0.8] and by 
reducing them we'd be reducing the costs [0.3] associated with premature deaths 
and illness [0.4] both to individual patients [1.1] and to the state [1.3] so 
the cost to the state of er [0.2] caring for people er [0.3] er who are 
experiencing the health effects [0.4] of [0.3] health inequalities is 
substantial [5.4] another reason is that because [0.2] if we don't take account 
of or you don't take account of health inequalities [0.5] in your medical 
practice [0.3] then your practice er can confound the effects [0.3] can worsen 
if you like [0.2] or make more complex the effects of [0.4] er poor masiterial 
circumstances on people's health and again we'll be looking at that issue [0.3] 
this afternoon [2.5] and lastly [0.9] we need to concern ourselves with ine-, 
inequalities actually 'cause the government says that you must [0.5] er [0.3] 
health inequalities is a key theme [0.3] in the government's health and social 
policy [0.4] and the government has 
put in place a number of policies which we're going to look at er [0.6] er in a 
minute [0.3] that have [0.4] that influence medical practice on a day to day 
basis [0.4] so you will be seeing [0.2] when you're out in in hospitals and in 
the community [0.4] er how medical practice is being shaped by [0.4] er 
initiatives from the government [3.8] so what i'm going to turn to now is to 
look at [1.3] what does the evidence say on how [0.2] health inequalities can 
be most effectively [0.2] tackled [1.7] so the main evidence that we can draw 
on are [0.2] evidence from a number of reports which took er [0.4] which 
reviewed all the evidence on health inequalities and [0.4] er put forward ways 
in which they thought health inequalities can be most effectively tackled [1.4] 
the Black Report er [0.5] you heard namex refer to [0.6] er those of you that 
came to namex's lecture [0.8] will er remember that namex [0.3] talked about 
the Black Report and the fact that [0.3] it was commissioned by the outgoing er 
Labour government in the late seventies [0.4] but reported to [0.4] the 
incoming Conservative 
government in nineteen-eighty [0.8] er [1.3] and er the report those of you 
who'll remember [0.2] Nick talking about how the report [0.4] really was wasn't 
circulated widely there was only about two-hundred copies of the report [0.3] 
actually distributed [0.3] because of the fact it was considered to be quite 
radical [0.5] er and that it wasn't in the government's interest to to 
circulate the report [0.4] but as things happen once you try to er [0.3] squash 
the circulation of something it has a life of its own and in fact was published 
as a Penguin book and was [0.5] and the re-, the findings were very widely 
publicized [1.2] but [0.2] Douglas Black er and colleagues er concluded that 
while [0.2] the health care service can pl-, can play a significant part in 
reducing inequalities in health [0.6] measures to reduce differences in 
material standards of living [0.2] at work and in the home [0.5] and in 
everyday social and community life [0.3] are of even greater importance so the 
Black Report was concluding [0.3] that we need [0.2] to er [0.4] give people 
better access to [0.3] er a a a better [0.2] 
standard of living at home and at work and in everyday life [1.7] the same 
conclusions were er [2.1] came to in a a report that was published in the 
nineteen-eighties which was [0.5] er [0.2] commissioned by the Health Education 
Authority called The Health Divide [4.0] neither the [0.4] findings from the 
Black Report or The Health Divide were er [0.6] put into action [1.0] so during 
er the nineteen-eighties we continued with er er a set of health policies [0.4] 
that were concerned with really [0.2] changing individual behaviour [0.4] 
rather than er aim-, [0.4] aiming at reducing health inequalities between 
groups [2.4] in [0.2] the nineteen-seventies or the late i'm sorry nineteen-
nineties er [0.3] with a new government came to power [0.4] er the [0.2] the 
government was it came into power commissioned a re-, [0.2] a an independent 
inq-, i-, inquiry [0.5] into that should say into inequalities in health [0.5] 
which was published er b-, in nineteen-ninety-eight [0.5] and this report was 
[0.2] chaired by Sir Donald Acheson [0.6] who er [2.9] w-, was [0.2] before er 
[0.5] this period had been [0.3] during the i think late 
eighties and nineties [0.3] the Chief Medical Officer for Health at the 
Department [0.5] at the Department of Health [0.8] er and he [0.2] also [0.2] 
prior to that was the dean of er [0.3] the medical school at Southampton [1.4] 
and in fact we were very lucky 'cause our guest lecture [0.4] lecturer here on 
the last day of the module last year was actually Sir Donald Acheson who came 
to talk about the independent inquiry [2.3] so [0.5] the independent inquiry 
into inequalities in health was [0.2] er commissioned [0.5] by the Labour 
government and reported in nineteen-ninety-eight [0.5] its remit was to review 
and summarize the evidence on inequalities in health in England [0.3] to 
identify priority areas [0.3] for the development of policy [3.2] but [0.4] it 
was limited to making recommendations that fell within the government's overall 
financial strategy [1.4] so this report [0.3] this er [0.5] er [0.6] inquiry 
reviewed and took evidence from [0.4] er a huge number of people and reviewed 
er all the re-, er the research studies within this area [1.6] er it drew the 
same conclusions as the Black Report and The Health Divide [0.6] and the report 
when it was published [0.3] was accepted by government with er some government 
action in key areas and that's what we're going to look at this morning [2.1] 
okay so it's if we think about what its conclusions and recommendations were [0.
7] er these were that firstly inequalities in health reflect [0.4] differential 
exposure across the life course [0.2] to the risks associated with socio-
economic permit-, er position [1.8] and it recommended [0.6] firstly a need to 
intervene on a broad front [2.1] it recommended the n-, er that it was 
important that poverty and income inequality were reduced [3.0] it said that 
people's er people in poor [0.3] social and material ne-, and [0.6] 
circumstanceses needed to have their material needs met [1.7] it said that 
parents and children should be given priority [1.7] and also that provision of 
equitable access to effective health care er [0.3] er was important [0.2] so 
i'm just going to talk about er some of these 
individually now [1.2] so let's take the first recommendation which was the 
need to intervene on a broad front [7.2] by this it [0.4] meant [0.2] that 
health inequalities need to be tackled at a number of levels [1.1] that it's 
less effective [0.6] to focus s-, [1.5] purely on any one point [1.9] that we 
need upstream and downstream approaches to tackling health inequalities [0.9] 
we need upstream approaches which deal with the wider influences on health such 
as income [0.4] benefits [0.4] employment education housing childcare [4.0] a-, 
and that we need these as well as approaches and this is the approach that's [0.
3] predominated in the past [0.5] as well as the the [0.2] the approach that 
only deals with the downstream aspects of health [0.3] such [0.2] aspects of 
health behaviour [0.4] such as lifestyles [0.7] smoking diet et cetera [0.9] so 
we need to look upstream to find out why people are falling into the river [0.
4] as well as downstream approaches that pulls them out [0.3] er and rescues 
them and gives them mouth to mouth re-, [0.2] er [0.8] mouth to mouth as the we 
pull them out of the 
river [0.5] so we need to look at why people [0.4] are falling into the river 
that's what's meant by upstream approaches [2.4] so what it means then is that 
we need to concentrate on [0.7] different [0.5] aspects er and different [0.3] 
er [0.6] influences on health [0.2] that it's no point these are the downstream 
approaches here [1.1] that it's [0.6] we won't reduce health inequalities by 
just trying to change aspects of individual lifestyle and health [0.2] and 
health behaviour [0.9] that we need to start to make changes and have policies 
that change the socio-economic the cultural [0.5] er environmental and material 
conditions that affect people in their everyday lives and are clearly the main 
influence [0.2] and main determinant [0.3] of how long people live [0.3] and of 
people's health experience [2.9] okay the second recommendation [0.3] was er 
reducing poverty [0.5] and this er [0.2] is er this was highlighted very 
clearly in the Acheson Report [0.3] that we were not going to er we're not 
going to reduce h-, health inequalities [0.4] unless we reduce poverty [4.6] 
okay [5.6] it drew attention 
to the need to reduce poverty in the U-K [0.4] because there has been a 
significant rise in the proportion of people [0.5] er who live in poverty in 
the U-K [1.1] and the way that we [0.2] measure poverty in the U-K [0.4] er or 
the main way that we look at poverty [0.4] er and i'll tr-, [0.3] t-, [0.5] 
draw a line between those if you like who er can be said to be living in 
poverty and those who are better off [0.4] is by looking at the proportion [0.
2] of households [0.5] or th-, or the proportion of individuals [0.4] who have 
incomes [0.2] which are below fifty per cent of average income [1.1] and you 
can see here from these figures in nineteen-seventy-nine we had about [0.4] 
nine per cent of the population [0.4] who had incomes that were less than fifty 
per cent of average income and that was about four-point-four-million [0.8] i'm 
us-, i'm going back to nineteen-seventy-nine because that's when er the figures 
are available from this it's from that date that this [0.3] these kinds of 
figures were collected [1.2] but we can see [0.7] by two-thousand two-thousand-
and-one 
we've had a substantial [0.5] rise in the proportion of people [0.4] who have 
incomes [0.2] of fifty per cent [0.4] er [0.9] of less than fifty per cent of 
average income [0.3] so the latest figure m-, figures we have from the 
government suggest that [0.5] virtually a quarter of the population [0.4] er 
live in poverty 
nf0268: we look at poverty in the U-K the figures that i've just shown you the 
national figures if you like [0.6] hide the distribution of poverty between 
social groups [0.5] er because different groups are at different degrees at 
risk of being in poverty poverty [0.4] like health is not equally distributed 
[0.4] between the population [3.4] er [0.2] households with er people with 
disabilities are much more likely than other households to have low income [1.
3] er we also know that black and minority ethnic households [0.2] are more 
likely to have incomes less than fifty per cent of average income [0.3] than 
white households [1.2] er and these are figures again from er the latest set of 
statistics on households below 
average income [0.2] which are published by er the government [0.3] and you can 
see [0.2] that households that er where the head identifies er [0.2] him or 
herself as as white [0.3] er a-, [0.7] about twenty-two per cent of those 
households [0.3] have incomes less than fifty per cent [0.2] of er average 
income [0.5] but you can see when we look at er particular [0.3] er ethnic 
minority groups [0.3] er we can see how the proportions er for these groups are 
significantly higher [0.3] than for those households that classify themselves 
identify themselves as as as [0.3] as white [0.2] and you can see that for some 
groups [0.3] er the proportions with of [0.3] households [0.7] of [0.2] with 
incomes of less than fifty per cent is very very high so if you look at the 
figure for example [0.6] for black non-Caribbean households [0.3] where it's 
half of all households have poverty level incomes [0.7] and you look at 
Pakistani and Bangladeshi households [0.3] er where sixty-nine per cent of 
those households have [0.2] er what can be ident-, classified as er [0.2] as 
living in poverty or having a poverty level income [0.2] of 
less than fifty per cent of average income [1.6] so some of those groups er are 
[0.2] living with very very [0.3] high levels of poverty [2.4] if we look at er 
poverty levels by different kinds of family [0.8] type [0.5] you can also see 
[0.2] that the type of [0.2] er [0.3] er [1.0] household that you are also 
increases your risk of being at poverty [0.2] being in poverty and you can see 
[0.4] that the group er [cough] [1.4] the largest group in poverty consists of 
[0.6] er households with children so for example [1.0] this is [0.2] all people 
are in poverty you can see that [0.3] over fifty per cent of all people in 
povert-, households in poverty is made up of [0.4] er households with children 
[0.3] so that's households where there's er [0.4] two adults and children [0.3] 
and also households where there are [0.3] er a single adult with children so 
we've got about fifty-four per cent of households [1.9] you can also see from 
this [0.2] that [0.3] er even [0.2] though er [0.5] for example when you look 
at pensioner households or pensioner couples households [0.4] er [0.7] they 
only constitute nine per cent [0.5] of the total number of people the total er 
number of people in poverty [0.3] but if you look at the the proportion [0.3] 
of pensioner households who are in poverty [0.3] then a quarter [0.4] of all 
pensioner households have poverty level incomes [5.3] [cough] okay so a key 
recommendation [0.2] er and a key way to reduce health inequalities [0.2] is to 
reduce poverty [3.4] the Acheson Report also recommended very clearly that [0.
5] er [0.2] policies should be aimed at [0.3] er [0.6] tackling and improving 
the health [0.2] tackling health inequalities [0.3] and improving the health of 
parents with children [0.8] and this is because health inequalities in adult 
life are set in part in utero [0.2] and in the first years of life [0.5] and i 
think we've heard namex talk about that and Nick Spencer [0.3] when he's 
talking about life course epidemiology [0.2] documenting very clearly [0.3] how 
er [0.3] health inequalities and er poor [0.3] poor health in adult life [0.4] 
er [0.8] is related to er [0.6] things like low birth weight health in utero 
and in very very early life [2.6] er [0.6] the government committed itself to 
eradicating child poverty in twenty years and 
halving it in ten [0.2] it took seriously its recommendation to to [0.3] er 
prioritize the parents and children and we'll see that later when we look s-, 
more specifically [0.5] at er some of the policies that the government's put 
into place [1.0] er and this is because er that households with children as 
we've just seen are the largest single group in poverty [1.0] about a third of 
all children are living in households with incomes less than than fifty per 
cent of average income which is really quite high a third of all [0.3] the 
country's children [0.2] have poverty level incomes and also [0.3] it's 
important because [0.2] child poverty rates er in Britain have increased faster 
[0.2] than those in other comparable countries [4.8] so [1.1] if [0.3] if we're 
looking at [0.7] this [0.6] we need to tackle on a broad front to reduce 
poverty [0.3] and to reduce mater-, er and to improve people's material 
conditions [0.4] and improve me-, people's material conditions by [0.3] giving 
them access to er [0.4] incomes which enable them to er have access to the 
sorts of lifestyles [0.2] and the material 
circumstances that they need for good health [0.2] like access to healthy 
housing and healthy environments [3.2] there are two [1.7] main ways that you 
can reduce poverty and improve people's li-, living standard [1.8] and these 
are [0.2] through er [1.7] initiatives and policies that improve [0.5] people's 
access to income in kind [1.4] and policies that improve access to income in 
cash [0.5] so by income in kind i mean er [1.5] not providing people with money 
in their hand but providing them with access [0.2] to [0.3] to [0.4] income in 
kind if you like through services that have no cost attached to them [0.7] so 
the N-H-S [1.4] er [0.3] indirect taxes like V-A-T [2.5] er education local 
government services [3.2] as well as providing or improving [0.6] access to 
income in cash through [0.2] employment policies wage policies [0.3] through 
regeneration programmes which i'm going to talk about in a minute [0.4] and to 
er by improving [0.3] income in cash through things like er [0.4] increases in 
benefits and pensions [1.4] just to show you why er [0.4] access to [0.4] 
income in kind is important [1.4] if we look at 
this slide [0.2] you can see that er [1.3] this is an analysis [0.2] by Shaw et 
al er and it's actually published in [0.4] er [0.2] the book The Widening Gap 
so those of you that have done the reading to prepare for today's session [0.4] 
may well have looked at this er slide because the data's in the book this is a 
summary of the data that you see published in the book [1.5] what they show 
here [0.8] is the amount of income [0.5] that er the poorest ten per cent of 
households [0.3] as well as the richest ten per cent of households [0.3] get 
from things like wages [0.7] from cash benefits [1.2] and also from benefits in 
kind [0.3] and what it shows is that to those who are very poor [0.5] and have 
poverty level incomes [1.4] that benefits in kind [0.5] make a substantial [1.
1] contribution [0.4] to the overall incomes of o-, [0.2] although it's not 
real money [0.3] er but it was real money this is what it would [0.4] 
contribute but it does make more of a [0.2] has more benefit for those who are 
in the poorest ten per cent of households [1.2] so if they didn't have that [0.
2] if you didn't have access to [0.6] benefits in kind [0.7] then this group of 
households would be substantially poorer [0.8] so for example if we 
had er a health care system that wasn't free at the point of access [1.7] er if 
we didn't have free education [1.7] if post-ta [0.5] tax income was structured 
differently [0.3] or indir-, indirect [0.3] taxes like er V-A-T [0.2] were 
structured differently [0.4] then this group [0.4] would be [0.2] much much 
worse off than they are now [0.5] so that's why it's important that [1.8] 
services like the N-H-S [0.4] er [0.2] are do remain free at access and are 
delivered in ways that are responsive to the needs of those who are the poorest 
[0.8] [0.9] just before we finish thi-, think it's important [0.2] to 
acknowledge that [0.5] while the independent inquiry said very clearly about 
how we need to tackle health inequalities and the government has taken [0.2] 
some of that on on board [0.4] the inde-, the the independent inquiry can be 
criticized for a number of reasons [0.4] er and it's er been criticized partly 
because [0.2] it didn't adequately prioritize [0.3] er its thirty-nine 
recommendations it made a huge number of recommendations [0.3] and things like 
poverty [0.2] er were easily lost in a sea of other recommendations [0.5] many 
of the recommendations were too vague [0.5] and the recommendations were not 
costed