Unequal from the start

Submission to the Labour Party Policy Forum February 2008

Inequality in health is at its most pronounced around the time of birth. Our government is committed to reducing health inequality in the population and is devoting considerable resources to the problem. Has the Socialist Health Association any new ideas to contribute? This paper attempts to consider issues around inequality from before birth and in the first year of life.

Infant Mortality

The infant mortality rate among the “Routine and Manual” group was 17% higher than in the total population in 2004-06, compared with 18% higher than in the total population in 2003-05, and 19% higher in 2002-04. This compares with 13% higher in the baseline period of 1997-99. So it is clear the target for reduction of this difference is not going to be met by 2010 unless something more is done.

Wider determinants of health

The most fundamental issue, which neither the Labour Party nor the Government cares to discuss is whether individual focussed efforts to improve behaviour have any chance of success when the wider causes of inequality are not confronted. The work of Sir Michael Marmot and Richard Wilkinson demonstrates very clearly that inequalities of wealth and income even among people who are not in any normal sense of the word “deprived” have a very strong influence on the health and life expectancy of the population. The other side of this debate, which some people in the public health community don’t seem to want to discuss, is what can be done to counter these powerful forces in the short term.

We remain convinced that a programme of redistribution of wealth along the lines which have evolved in the Nordic countries would do more to improve the health of the population than any other measures. However the political situation in the UK, in particular the leverage exerted by a small number of middle class voters in a few middle class constituencies, makes talk about redistribution very unwelcome amongst politicians who have to face the electorate. Political leadership which is capable of making a coherent and convincing case for a more equal society has not emerged. Although there are many politicians in all parties who appear to genuinely espouse the idea of redistribution none have managed to resist the pressures from the articulate middle classes to, for example, reduce the burden of inheritance tax.

There is little absolute poverty in the UK other than the destitution which is used as a political weapon by the government against asylum seekers. Those failed asylum seekers, who are literally destitute, are of course often of childbearing age, and may make a decision that it is better for them and their families to be destitute in London than in Mogadishu or Harare. We are not convinced that the decision to withdraw both support and free medical care from this group is rational from the perspective of the tax payer. If their babies end up in paediatric intensive care, or the mothers die in childbirth that will cost a great deal more than will be saved by denying them primary care. However this problem raises much wider questions than can be dealt with here.

There is, however, a great deal of relative poverty in the UK, and its burden falls particularly on those of childbearing age. The weekly rates of means tested benefits for a person aged 16-17 are £35.65, for a person aged 18-24: £46.85. For people over the age of 60 the rate is £119.05 a week. Rates of payment for those supported by the National Asylum Support Service are about 70% of that. It is hardly surprising that some of these young people are socially excluded and live unhealthy lives. Of course it would be better if they were working or studying, but there are often reasons which make these ambitions difficult to realise, and pregnancy is one of them.

Reducing inequalities in the population, even if it is attempted, will take time. Globalisation makes the problem of inequalities far more difficult to tackle. So in the short term at least we need to focus on initiatives which are more politically acceptable. This means an ecological approach which encompasses within a single framework measures to encourage people to adopt healthy lifestyles – for example provision of cycle paths – and measures to discourage unhealthy behaviour such as more taxation on booze, bans on advertising etc.

Evidence of what works

The Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study seems to provide a quite convincing basis on which health intervention at the level of individual behaviour could be evaluated. These findings indicate that the combination of four simply defined health behaviors predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. They also show that the risk of death (particularly from cardiovascular disease) decreases as the number of positive health behaviors increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be confirmed in other populations and extended to an analysis of how these combined health behaviors affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. Armed with this information, public-health officials should now be in a better position to encourage behavior changes likely to improve the health of middle-aged and older people.

This important study was conducted among middle aged people and clearly does not apply directly to young women. But it would be very surprising if the same factors (smoking, drinking, diet and exercise) did not affect younger people and if the multiplier effect did not apply to them. If the government are serious about reducing health inequalities in children we need to move to assessing impact of all current and proposed policies on child health

Policy issues

50% of conceptions are unplanned, so it is difficult to identify which women are (or may soon be) in early pregnancy. There are many valuable interventions which can be undertaken with different groups to address aspects of early pregnancy, eg alcohol consumption, diet, smoking. We need to develop more creative approaches to promoting good health in pre-conception and early pregnancy.

Teenagers, especially girls, need a diet rich in calcium and iron, but they often don’t have one. Problems relating to body image are critical at this time in a woman’s life, and of course relate chiefly to self esteem and the behaviour of boys. Messages from health professionals are drowned out by commercial and social pressures to conform.

Young mothers tend to present late to maternity services. We need to try to make services more welcoming to them and more relevant to disengaged young people. We need a longer period of paid maternity leave, a significant extension of paid leave for fathers/partners, and the right to request flexible working for all parents. Improving rights at work for parents are of little help to young people who are not in legitimate employment, and there is reason to believe that young people are disproportionately affected by vulnerable employment. There is still considerable prejudice amongst employers (and some employees) against women who exercise their rights to maternity leave. In relation to health and safety issues, few employers have a good understanding of their obligations to undertaken and act on risk assessments for pregnant employees and those returning to work within six months of the birth or is breastfeeding. Relying on employees to request a risk assessment and insist on appropriate changes to their work places an unreasonable burden on mothers and is likely to impact on the health of mothers and their babies.

There is a continuing rise in the proportion of births to mothers born outside the UK: 21.9 per cent in 2006. There is a similar rise in the numbers born to BME mothers who were born here. Both the stillbirth rate and neonatal mortality rate are higher in women of Black, Asian or Other ethnicity. Vitamin D deficiency is a widespread problem among BME women. Healthy Start women’s vitamin supplement contains folic acid and vitamin D for preconception, pregnancy and throughout breastfeeding. We think this should be made freely available without charge. The fact that some women have to pay makes it much more difficult to distribute. Given the low cost and high benefits we think that everything possible should be done to ensure that the vitamins reach all at risk women. It is by no means clear that services are always culturally appropriate for BME women. Nor is it clear that government policy initiatives sufficiently address the position of mothers in BME communities. There has been a lot of talk about choice in maternity services over the last 15 years, but not a great deal of delivery (pardon the pun).

There is plenty of evidence about the long term costs of low birth weight babies and the effect of maternal deprivation, but the resources devoted to dealing with the problem are not in proportion to those costs.

There is considerable evidence that measures which are officially promoted – such as nicotine replacement therapy for pregnant women – are not delivered consistently. The most obvious is the promotion of breastfeeding. It is clear that even within NHS organisations the messages about the importance of breastfeeding have not been accepted or implemented. Breast feeding has immensely beneficial effects, but the resources needed to help women to do it are not forthcoming. Another neglected issue is the spacing of births. In other parts of the health service the principle of “invest to save” is well established. Why not here?

There are still problems with social and relationship education, which seems to be handled better in other European countries. Secondary schools, and parents, are still very anxious about discussing issues relating to sex. It is pretty unclear who, if anyone, takes responsibility for developing life skills in this area. This leads to more risky behaviour among young people. Girls are blamed for “getting pregnant” and boys know little or nothing about issues like breast feeding. Sex education should start much earlier, in primary school, and the idea that it is an optional extra for schools must be abandoned. The country in Europe with the lowest teenage pregnancy level is Holland – the country which starts sex education earliest.

Training in diversity for health staff does not extend to issues relating to poverty, and many well meaning health initiatives fail because social issues (such as the importance of territory on housing estates) are not taken into account.

Government Initiatives

1.Support for families through Children’s Centres: currently over 1,750 centres are open, with 2,500 planned for 2008 so that all the most disadvantaged areas have a centre, with 3,500, one in every community, by 2010. Will these centres just provide childcare, or will they address other needs?

2. Extended schools offer pupils, families and community members quick and easy referral to services, including health services, on and off site and Healthy Schools take a whole-school approach, including parents, to promoting better health through national standards in healthy eating, physical activity, emotional health and wellbeing, and personal, social and health education.

3.Family-Nurse Partnership demonstration sites, – parenting support delivered by health visitors can improve life outcomes for young first time mothers and their children. All first-time mothers under and up to the age of 20 are referred to the demonstration sites but the sites aim to focus on the more vulnerable: factors taken into account include age, income, family support and marital status.

4.Early identification of at risk families and plans to make breastfeeding the default option for mothers.

5.Investment in healthy schools, increasing participation in physical activity, and making cooking a compulsory part of the national curriculum.

6.A £75 million marketing campaign to support and empower parents to make changes to their children’s diet and increase levels of physical activity.

7.£190 the Health in Pregnancy Grant, from April 2009

8.Child Benefit from the 29th week of pregnancy – we would like to see this start much earlier

9.Sure Start Maternity Grant £500 at week 29

10.Healthy Start Vouchers £2.80 per week from week 10


There are considerable difficulties in the management of the public health workforce. While it is now established that medical qualifications are not required for Directors of Public Health health visitors are being suppressed as a profession by the Nursing and Midwifery Council, which is insisting that Health Visitors who came through the midwifery route must continue to practice as midwives for 450 hours a year. At the same time spearhead PCTs are being encouraged to employ health trainers directly recruited from disadvantaged communities. We think this initiative may be productive, but at the same time various public health specialist interventions are being planned. The specialists and generalists need to be formed into coherent teams so that those without clinical training can access specialist support when necessary and those without the benefit of roots in local communities can access that knowledge and experience. Staff with sufficient experience and strategic vision are needed, for example, to work as school nurses. Directors of Public Health should be providing professional leadership and management of what is now a substantial workforce. The way that public health budgets have been systematically raided to prop up acute services has left the workforce demoralised and disorganised. Real co-operation between health and local authority services is needed, but is by no means universal. We would like to see much closer integration and more joint appointments. We need to ensure that there are sensible career pathways in public health and get rid of the notion that the only people who can join the profession at a level with decent pay, or progress in their careers are those who have already qualified in clinical work. At present nobody seems to be taking any responsibility for the coherent development of a public health workforce.