Health inequalities matter, and they are getting worse. One of the most common measures, life expectancy, is now falling in certain groups and locations, as it continues to rise in areas defined as more wealthy.
This has not escaped the notice of the government: the Labour party’s manifesto contained explicit statements about tackling health inequalities. We support the determination – but appeal for caution.
The term ‘health inequalities’ needs defining as precisely as possible, if policy to lessen them is to be at its most effective. Which groups of people are being compared? For what outcomes? Which proxies – a common tool in the field of health inequalities research – are being used to delineate groups of people (postcode, occupation, etc, often in combination)? How much attention to the likely causes for health inequality (summarised as structural, psychosocial and ‘lifestyle choice’ by key policies and research since at least the 1980s) will be given in framing policy?
Now of course any government will have access to the best possible advice – Sir Michael Marmot’s Institute of Health Equity and the work of the Health Foundation stand as shining examples amongst many others in the UK alone. But the devil lies not so much in the detail as in the politics. It has always been fiercely difficult to take a sufficiently long and deep view of lessening health inequalities in the lifetime of any single parliament, and across so many different functional areas (health, social care, housing, environment, employment, amongst others). Policy makers are presented with many conflicting priorities and the need to ‘show results’ in a few short years, if only to justify the public expense. There remains a tangible risk of falling back on tackling the causes that present not the most effective (as part of a complex mix requiring overall application) solution but the most demonstrable, with ‘lifestyle choice’ (sadly in reality often a lack of choice for the individuals most affected) seeming to be a prominent ‘fall back’ target. But doing this can all too easily fail to bring about the wished-for change, and all too often lets in one of the spectres of health inequalities to cause more damage than good: deservedness (‘they brought this on themselves; it’s their fault’). There is also now the uncomfortable reality that should ideally never exist if there is a national health service: those people in most need who are the least able to change their circumstances are increasingly and unequally affected by problems in accessing healthcare in a timely way. The return of the inverse care law is now a political reality. This can only add to the problems of health inequality, as people unable to receive timely health care and facing multiple causes for health inequality already can only be at greater risk of even poorer health.
But this can be done: health inequalities can be tackled, and people’s lives can be improved with determined policy. We wholeheartedly support the political will to advance that determination, bearing in mind all of the daunting but not insurmountable difficulties that present themselves.
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