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