Amongst the key objectives of the SHA, as expressed in our mission statement, is the eradication of inequalities in health. To achieve this end we must increase our impact as a campaigning organization. To do so requires the development of clear and digestible policies that can be readily understood by experts and lay-people alike. We believe that the breadth of our membership, coupled with the depth of their knowledge and experience place the SHA in a strong position to inform, influence and lead the wider Labour movement and the public debate.
This paper will form the foundation of our campaign on health inequality. We recognize that there exists a spectrum of views across our membership on every issue; previous attempts to summarise the association’s policy position have proved trying if not impossible as a result. The purpose of this paper is therefore not to define the diverse beliefs of our membership. Instead, it presents arguments and policies consistent with our long-agreed principles for the purpose of campaigning in this crucial area of public policy.
Health inequality in Britain today
It is an off-quoted statistic that, with each mile traveled along London Underground’s Jubilee line east from wealthy Westminster to deprived Canning Town, the population loses one year of life expectancy. Indeed, the gap in life expectancy between richest and poorest stands at a decade and grew by around 2% from 1999-2006. Infant mortality (often taken as a marker of the quality of a nation’s healthcare) amongst the poorest is double that of the richest babies.
Why health inequality matters
Our first task must be to articulate why society should concern itself with health inequality. For many, successful health policy is defined by increased average life expectancy for the country as a whole. For others, such as Tony Blair’s former policy advisor Julian Le Grand, increasing life expectancy for the poorest is a sufficient goal, even if the gap between them and the wealthiest grows. There are three key arguments in favour of a more ambitious approach to inequality itself.
The technical argument – we can do better
The poorest experience health outcomes significantly worse than those that are possible in the UK today. If the purpose of healthcare is to reduce illness and increase wellbeing, we fail to do so adequately for millions of Britons. Improvements in outcomes alone will never provide everyone with the best possible health at any given time unless the poorest catch up with the richest.
The centrist argument – the immorality of inequality
Inequality in something as fundamental to our lives as health is unacceptable. It is also contradictory to the founding principle pf the NHS, to which all major parties are signed up. The purpose of providing healthcare free to all at the point of use was to reduce (indeed eradicate) the burden of ill-health suffered most by the poorest, not just to equalize the provision of healthcare itself.
The growing Left consensus – the good society is the equal society
Everyone’s health is improved by creating a society with more equal outcomes. In every society, there exists a gradient of health from the healthy rich to the unhealthy poor. However, it is not only those at the extremes of the income scale who experience inequality. Even those in the middle have poorer outcomes than their richer neighbours. Indeed wherever you are on the income scale, those above you will be healthier.
The difference between more and less equal societies is the steepness of the income (and therefore health) gradient. In more equal nations, although wealth still buys you health, they both decline less steeply across the population. As a result, not only is the health of the poorest improved, so too is that of the vast majority.
Health inequality is therefore far from being a marginal issue. It is central to how to create a healthier country. Moreover, there appears to be a growing consensus on the Left in favour of defining the good society as one that has equality of outcome, not just equity of access, at its core.
Our policy position
Despite its best intentions, New Labour has failed to couple increased wealth with reducing inequalities. It has sought to do so by targeting resources at the poorest (child and pensioner poverty, homelessness etc.) and seeking to foster meritocracy whilst tolerating rising income inequality. In health, Alan Johnson recently announced £34 million of additional funding for a range of targeted interventions in areas with the greatest health needs. This investment comes hot on the tail of a range of other targeted initiatives such as Health Action Zones. This approach – targeting the poorest, whilst tolerating growing income inequality – has proved to be unsuccessful. The following four overarching points focus on a few key political arguments that stem from the above analysis.
1.Income inequality is the key
A wealth of evidence (some of it referenced above) points clearly to a correlation between income inequality on the one hand, and health inequality, drug addiction, crime, family breakdown, trust and a whole range of other social parameters on the other. Without making our post-tax, post benefits incomes more even, we cannot reduce the stigma associated with being less successful than our neighbours and thereby mitigate the psycho-social pathways that lead to falling health outcomes down the income scale.
Thus, interventions targeted at the poorest, whilst helpful, cannot be the key focus of public policy. Indeed, in political terms, they could be viewed as a distraction from the main imperative to equalize incomes.
Universal, well-funded services are the best mechanism of redistribution
Earnest attempts have been made to redistribute income by Labour over the last decade. Tax credits, the best known of these measures, have undoubtedly slowed what would have been a rapid rise in income inequality. Nevertheless, income inequality has continued to grow under Labour, with the top 20% of earners in particular enjoying a disproportionate chunk of the nation’s wealth5. Moreover, tax credits, by tying millions into means-testing, have perpetuated the very stigma of inequality that redistribution is designed to mitigate. Finally, direct, means-tested benefits of this kind are fragile in political terms, because they provide nothing for the most powerful segment of society (the richest); at times of economic hardship, they will be the first to go.
Redistribution is therefore best achieved through universal benefits (e.g. child benefit) and, in particular, benefits in kind, in other words, free public services. In this way, wealth is spread from the richest to the rest of society according to need, without generating stigma and is an articulation of the principle of Progressive Universalism.
Equality not just equity
In the public and political debates on health inequality, much is made of the unequal access to medical services known as ‘the inverse care law’. It is best exemplified by the distribution of general practices in the UK, which are more concentrated in areas of wealth than in those of need. Whilst this inequitable distribution of resources exacerbates health inequalities, it is crucial that we do not allow it to be conflated with or to override the fundamental issue of unequal outcomes. We should focus on the means of healthcare only inasmuch as they affect our ends, namely achieving greater health equality.
The prescription charge should apply just once per prescription, regardless of how many items are included.
Free school meals for all, to promote healthy eating and ethical consumerism. Meals would not be obligatory but would be encouraged an important part of a child’s education.
Increase the minimum wage over time to a living wage.
Raise taxes on the top 20% of earners.
Raise child benefit.
2.Public health on a national scale
Inequality in income and status drives inequality in health. It does so through factors such as unemployment, poor housing, and limited educational attainment. In turn, such factors lead to illness (mental illness in particular) and lifestyles that cause illness – poor diet, smoking, inactivity.
The health service and government intervention more generally should attempt to tackle these ‘downstream’ consequences as well as their underlying causes. Indeed, as there will always be inequality, doing so will always be necessary.
Introduce a ban on the marketing of foods high in salt, sugar and fat, targeted at children
Introduce compulsory, front-of-pack, “traffic-light” information for consumers about the health of food they buy. This should be extended over time to food and drink which is provided for immediate consumption. Consider imposing VAT on the most unhealthy food.
Raise the legal age for purchasing tobacco from 18 to 21 and work to increase the price of tobacco across Europe to reduce smuggling.
The number of units of alcohol contained within a container should be displayed on the front, in order to promote a more healthy consumption of alcohol.
Tax on alcoholic drinks should be proportional to the quantity of alcohol the contain.
Initiate measures to raise the price of alcohol across Europe in order to reduce smuggling.
Ban alcohol sponsorship and advertising for sporting events and consider wider restrictions on advertising.
Increasing the proportion of journeys made on foot is our central transport target and will require a substantial change in the way in which we approach the design and use of roads and streets.
Measures should be implemented to reduce the number of children traveling to school by car when they could walk.
3.Community Health Centres at the heart of the NHS
So, what can healthcare do to mitigate the health inequalities that arise from wider social inequalities? Dealing with inequality downstream requires a focus on the community. For the NHS that means general practice, health visiting, community midwifery and community nursing, in collaboration with public health. Our vision is of an integrated service provided through health centres, along the lines of the Peckham Health Centre. The main purpose of community services would thus become the mitigation of inequality and the promotion of health, rather than the treatment of illness per se.
Where inequities in access exist, they should of course be eradicated. In particular, the perverse distribution of GPs that favours the rich must be reversed, not just through ad hoc measures (as recently announced in the Darzi next stage review) but as a permanent tenet of the NHS.
Polyclinics and the ‘GP-led health centres’ proposed in the Government’s Darzi review should do more than widen access to treatment for ailments. Whilst equitable access is necessary to achieve equality of outcome, it is far from sufficient. Instead, these new clinics should provide a range of community services, from sexual health to employment advice. Their primary purpose should be the reduction of inequality in health through prevention.
Roughly 10% of the NHS budget should be allocated to prevention
A well-trained, well-funded universal health visitor service should be available and accessible to support all parents of children under five with specialist help for the most vulnerable families.
Occupational health services should be available to everyone through the NHS.
4.The NHS as exemplar
As Europe’s largest employer, the NHS could be a powerful example of responsible employment.
Introduce a boosted, in-house minimum wage
World-leading occupational health
In-kind benefits, such as subsidized sporting facilities
A procurement policy that favours other responsible employers
Addressing health inequality is central to improving the health of the nation. It affects everyone in society, not just the least well off, and contributes to the social tension and decay that are a growing part of today’s Britain. Therefore, rather than focusing on the least well off, policy should be progressively universal. The main driver of health inequality is income and status inequality. These must therefore be our central priority. However, prevention of the downstream consequences of inequality can be effected through both national initiatives and more consorted action through community health centres. Finally, the NHS itself, often the largest employer in a local economy, must show leadership in ethical, enlightened employment practice.
Author: Neil Goulbourne