Reducing health inequality

As well as improving the health of the population in general it has been a long-standing objective of public health policy in the UK to reduce health inequalities. There have been a series of major reports into public health in the UK focusing on inequalities in health access and outcomes, starting with the Black Report,^[1] which was published in 1979. The report investigated the inequality of healthcare such as the differences between the social classes in the usage of medical services, infant mortality rates and life expectancy. The Whitehead report in 1987, the Acheson report in 1998 and the Marmot review in 2010 investigated similar concerns.

Fair Society, Healthy Lives, the 2010 report of the Marmot Review reported that people who lived in poorer areas die sooner, and spend more of their lives with disabilities.  The review highlighted a social gradient of health inequalities (see Box 1), in simple terms -the higher a person’s social position, the better their health is likely to be. 

The review stated that reducing these inequalities would require work across all determinants of health and recommended action in the following six policy objectives:

• Give every child the best start in life

• Enable all children, young people and adults to maximise their capabilities and have control over their lives

• Create fair employment and good work for all

• Ensure healthy standard of living for all

• Create and develop healthy and sustainable places and communities

• Strengthen the role and impact of ill-health prevention.^[2]

The Healthy Lives, Healthy People White Paper, published on 30 November 2010, responded to the Marmot review and set out the Coalition government’s long-term vision for the future of public health in England. It took the view that the balance of responsibility and action should shift from central government to local communities, and that people should be supported to take on more responsibility for their health.  The Healthy Lives White Paper reported that changing adults’ behaviour could reduce premature death, illness and costs to society, avoiding a substantial proportion of cancers, vascular dementias and over 30% of circulatory disease; saving the NHS much of the estimated £3.5 billion cost of alcohol misuse; and saving £13.9 billion a year, the societal costs related to drug-fuelled crime. 

The Health and Social Care Act 2012 transferred responsibility for commissioning the majority of public health services in England from primary care trusts (PCTs) to local authorities and established Public Health England, which took on responsibilities to oversee the local delivery of public health services.  There is a Commons Library Standard Note (SN/SP/6844) on local authorities’ duties to improve public health.

An Office of National Statistics report published in November 2015 (looking at the 2009-2013 period) showed that wide inequality in health still exists, not only between different parts of the country but even within local authority areas. The report concluded that there had been little change in inequality over the last decade.[3]

Persisting health inequality in the UK has been a subject raised in a recent House of Commons Health Select Committee Inquiry on public health. The September 2016 report states that, as well as focusing on public health, reducing health inequality will require that wider determinants of health, such as housing and education will need to be addressed.  The Report also states that cuts to public health are a false economy, and the funding provided needs to match the commitment to public health in the NHS Five Year Forward View.  The Report calls for the embedding of health in all policies, including making it a material consideration in planning and licencing decisions.  The Government response to the Committee’s report has not been published yet. 

In response to a PQ in July 2016, the then Minister for Public Health Jane Ellison set out that reducing health inequalities is a priority for the Government:

Reducing health inequalities is a priority for this Government.

The Department takes a comprehensive and strategic approach to tackling health inequalities that addresses the wider social causes of ill health, promotes healthier lifestyles for all, tackles differences in both access to, and outcomes from, health and public health services. Action is led locally to ensure that the solutions put in place reflect the needs of individual communities.

Achieving measureable and sustained reductions in health inequalities is integral to the Department’s Shared Delivery Plan 2015-20, and reflected in the Government’s mandate to NHS England, Public Health England’s (PHE’s) Evidence into Action and supporting strategic and business plans at national and local level. NHS England’s Business Plan for 2016/17 prioritises closing the gap for groups experiencing poorer health outcomes, a poorer experience of, and access to, healthcare. PHE is supporting local and national efforts to address health inequalities by providing knowledge and intelligence, and evidence-informed tools and advice.

To support this, the Department has published Improving outcomes and supporting transparency: A public health outcomes framework for England 2013-16. The framework’s vision is to improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest. It is focused on the two high-level outcomes we want to achieve across the public health system and beyond. The first is increased healthy life expectancy; the second is reduced differences in life expectancy and healthy life expectancy between communities through greater improvements in more disadvantaged communities. ^[4]

[1]     Working Group on Inequalities in Health, Inequalities in health: report of a research working group [Black Report] (chaired by Douglas Black), DHSS, 1980

[2]     Professor Sir Michael Marmot, Fair Society, Healthy Lives. The Marmot Review (2010)

[3]     https://www.gov.uk/government/news/inequalities-in-health-and-life-expectancies-persist

[4]     PQ 42294, 14 July 2016