Health variations Newsletter
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Issue 2, July 1998, pp. 2-3.

Health inequalities and the public health Green Papers
Hilary Graham

Introduction
Public health Green Papers have been published in Northern Ireland (December 1997), England (February 1998), Scotland (February 1998) and Wales (May 1998).(1-4) While there are differences in emphasis and approach, they share an analysis of the UK's health problems. The analysis is based on a recognition of:

  • the fact and scale of health inequalities;
  • the link between health inequalities and wider inequalities in life chances and living standards;
  • the need for policies which tackle these broader social causes;
  • the potential contribution of area-based interventions.


In each of these respects, the public health strategy of the Labour government marks decisive break with policies a pursued since the late 1970s.

Recognising health inequalities
The Green Papers provide a succinct summary of the inequalities in morbidity and mortality which scar the UK's health record. We learn that children in Northern Ireland born into a manual working class family have a mortality rate in the first year of life which is 20% above the rate among children in professional and managerial families.(1) The English, Welsh and Scottish Green Papers describe the pronounced socio-economic differentials in mortality, and note that these differentials are increasing.(2,3,4)

Recognising the link with social inequality
In contrast to the approach favoured by the previous government, health inequalities are named in these terms and their causes are traced back to the broader structures of inequality. There are recurrent references to what are called the root causes of ill-health, to 'the underlying social, economic and environmental circumstances which influence health.'(3) The contribution of smoking, diet and exercise is recognised but - again in contrast to the previous government - lifestyle factors are seen as shaped by the broader circumstances of people's lives.

'The causes of inequalities are complex and not fully understood. However, it is clear that many of the major inequalities are associated with disadvantage, whether this is measured by income, level of educational achievement or occupation. Factors which affect health and well being, such as poverty, unemployment, inadequate housing, lack of social support and low educational attainment are more common in disadvantaged neighbourhoods and groups. The same applies to factors associated with personal behaviour - smoking, eating the wrong sort of food, drinking too much or taking too little exercise.'(1)

Tackling inequalities
Recognising that health inequalities are the outcome of broader social inequalities, the Green Papers are cautious about how quickly and how far health inequalities can be reduced. There are, as one Green Paper observes, no 'quick-fix' solutions! Nonetheless, they make clear the government's commitment both to improving health and to reducing health inequalities.

'The Government has two key aims (for England):

  • to improve the health of the population as a whole;
  • to improve the health of the worst off and to narrow the health gap.'(2)

    'The strategy for a healthier Scotland must be a strategy for the whole population, but must at the same time tackle health inequalities through giving the highest priority to those who have the most disadvantaged lives and the greatest needs.'(3)

    'The Welsh Office is concerned not only with improving the health of the population as a whole, but also in pursuing policies that will have maximum impact on those sections of the population that suffer the worst health.'(4)

All four Green Papers recognise the importance of setting milestones by which progress towards the twin public health goals can be measured. However, while proposals for targets to improve health are described in some detail, little is said about targets towards reducing inequalities. The Welsh Green Paper, however, includes a proposal 'to develop in consultation with key agencies, a number of priority targets for the reduction of inequalities in health in Wales.'(4)

Emphasising area-based initiatives
The Green Papers layout a programme of action at national, local and individual level to tackle health inequalities. National policies are seen as being primarily concerned with the 'upstream' socio-economic determinants of health inequalities, with welfare-to-work, the national minimum wage and better housing figuring prominently.

Regional and local initiatives are seen to 'add value' to these national policies, by targeting additional investment in areas of high social and health need. In Scotland, for example, it is proposed to strengthen existing programmes of area regeneration, using the inter-agency structures and community links established through these programmes to develop work to tackle health inequalities. In Northern Ireland, the Targeting Health and Social Needs initiative will be developed to implement and evaluate interventions to reduce health inequalities. The Welsh Green Paper emphasises the potential of local agenda 21 strategies, with the principles of sustainable development applied to local areas. Our Healthier Nation announced that 'the Government is setting up Health Action Zones to tackle health inequalities', a policy it has now implemented (see article by Linda Bauld and Ken Judge, Health Variations Programme Newsletter, Issue 2, pp.10-11).

These targeted initiatives are designed to regenerate the social as well as the economic fabric of disadvantaged communities. Social isolation and social exclusion are seen as barriers to reducing health inequalities, because 'whatever the cause, socially excluded groups suffer more ill-health and poorer social well-being.'(1)

In contrast to Conservative health policy, the importance of community development is underlined, with its principles to be extended and mainstreamed within health and local authority agencies.

'A key task is to help strengthen communities in need, promoting a sense of belonging, hope, self-esteem and confidence.'(3)

'The plans will promote and employ community development approaches. Community development involves supporting local communities to identify the health and social concerns of greatest importance to them and helping them to devise and implement solutions. The Government wishes to see community development further extended, strengthened and promoted in Northern Ireland.'(1)

Conclusion
The new public health strategy has an ambitious goal. It seeks to improve health and reduce health inequalities through a blend of national policies and area programmes. Key questions raised by the strategy are how areas influence the health of those who live there and how area-based initiatives will tackle these influences. Four articles in Newsletter Two focus on these central questions.

References:
1. Department of Health and Social Services (1997) Well into 2000: A Positive Agenda for Health and Wellbeing, Belfast : The Stationery Office.
2. Secretary of State for Health (1998) Our Healthier Nation: A Contract for Health, London : The Stationery Office.
3. Scottish Office Department of Health (1998) Working Together for a Healthier Scotland: A Consultation Document, Edinburgh : The Stationery Office.
4. Secretary of State for Wales (1998) Better Health Better Wales: A Consultative Paper, Cardiff : Welsh Office.

Hilary Graham is Director of the ESRC Health Variations Programme and Professor of Social Policy at Lancaster University.