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Issue 3, January 1999, pp.2-4.

Inquiry into Inequalities in Health
Hilary Graham

Introduction
The long-awaited report of the Independent Inquiry into Inequalities in Health was published in November 1998. This article describes the background to the Independent Inquiry and highlights key features of its report.(1)

Background to the Inquiry
The background to the Inquiry lies in a simple but stark fact. Across the last two decades, Britain has got richer and healthier but inequalities in income and in health have widened markedly.

With respect to income, average living standards (as measured by average incomes) have risen in real terms by 40% since 1979. But the benefits of increasing prosperity have been unequally shared. Among those at the top of the income ladder, real incomes (after housing costs) grew by 60%; among those at the bottom, they fell by 8%? The result has been a sharp rise in the proportion of the population, and particularly the proportion of children, living in households below the EC poverty line (see Figure 1).

Figure 1: Proportion of people and children below 50% of average income (after housing costs) 1979-1995, UK.

Source: Department of Social Security, Households Below Average Income, (reports for 1979-1995).

With respect to health, death rates have fallen and life expectancy has risen. But socio-economic inequalities in both dimensions of health have increased. In the early 1970s, death rates among men of working age were almost twice as high in social class V as in social class I; by the early 1990s, there was a three-fold class differential(3) (see Figure 2). Many of the major causes of death in adulthood, like coronary heart disease and cancer, can be traced to exposures and experiences earlier in life. For example, childhood exposure to disadvantage is associated with poorer health in infancy and childhood and on into adulthood. An increase in childhood poverty has therefore profound implications for health inequalities in both current and future generations.

Figure 2: European standardised mortality rates by social class, men aged 20-64 (all causes), England and Wales

Source: Drever, F. and Bunting, J. (1997) 'Patterns and trends in male mortality' in F. Drever and M. Whitehead (eds.) Health Inequalities, London : The Stationery Office.

The policy response
The government has put the reduction of health inequalities at the heart of its public health strategy. Within weeks of the May 1997 election, a Minister for Public Health was appointed to lead this strategy in England and a scientific inquiry was established to inform its development. The public health strategies launched in England, Northern Ireland, Scotland and Wales are built around the twin aims of improving the nation's health and reducing health inequalities (see Hilary Graham's article, Health Variations Programme Newsletter, Issue 2, pp. 2-3).(4-7)

The Independent Inquiry into Inequalities in Health is an evidence-based review of the policy options to take forward this public health agenda. It was vested with the task of reviewing the evidence on health inequalities in order to identify priority areas for the development of policies to reduce them. The five-person Scientific Advisory Group was chaired by Sir Donald Acheson and conducted its inquiry between September 1997 and July 1998.

The Independent Inquiry follows in the footsteps of earlier government-authorised reviews of science and policy in the field of health inequalities. The last Labour government established the Research Working Group on Inequalities in Health in 1977, chaired by Sir Douglas Black. The Working Group reported to the incoming Conservative government in 1980.(8) Its report was shelved and its recommendations were dismissed with what the British Medical Journal described as 'shallow indifference'.(9)

By the early 1990s, evidence of widening inequalities was prompting increasing public debate and professional concern. In 1995, another official enquiry was initiated, this time as part of the Chief Medical Officer's review of England's Health of the Nation strategy. Variations in Health; What Can the Department of Health and the NHS Do? was published in 1995.(10) While its terms of reference were limited and inequality was neither named or shamed, the underlying analysis was clear. Inequalities in health were seen to be the outcome of socio-economic inequalities in living standards and life chances, with these broader inequalities taking a culminative toll on health through childhood and across adult life. The report concluded that, without policies to address them, variations in health could be a serious barrier to the achievement of national health targets. In other words, tackling health inequalities is an essential prerequisite for wider gains in public health. It is a message underlined both in the World Health Organisation's (WHO) current Health for All strategy and in its new strategy for the next century. In Health 21, its new health strategy for Europe, reducing health inequalities is again seen to hold the key to improving health for all.

A socio-economic model of health inequalities
The report of the Independent Inquiry opens with a review of the evidence on health inequalities - relating to socio-economic status, gender and ethnicity - and on trends in their socio-economic determinants. The second part of the report is devoted to identifying and recommending areas for future policy development and evaluating the evidence on the potential benefits of investing in these policy areas.

Like the Black report and the report on Variations in Health before it, the Independent Inquiry's review of the scientific evidence leads it to a socio-economic model of health inequalities. This is one which tracks socio-economic inequalities in health back, through individual lifestyles and the material and social environment in which they are sustained, to deeper structural inequalities in the distribution of wealth and opportunity.

'Socioeconomic inequalities in health reflect differential exposure - from before birth and across the life span - to risks associated with socioeconomic position. These differential exposures are also important in explaining health inequalities which exist by ethnicity and gender.'
Independent Inquiry into Inequalities in Health, 1998, p.6.

Multiple causes point to the need for wide-ranging policy solutions. However, while the evidence on causes highlights macro-level influences, the evidence on interventions relates to micro-level factors. This is because, as the Inquiry puts it, 'the more a potential intervention relates to the wider determinants of inequalities in health, the less the possibility of using the methodology of a controlled trial to evaluate it'.(11) As a result, the Inquiry draws on a wide range of evidence to guide its judgements about how to address the structural and macro-level determinants of health inequalities.

The research and policy communities played an essential role in furnishing the Inquiry with the evidence it needed to identify priority areas for policy. Over 170 organisations and individuals submitted evidence, including voluntary organisations, local councils, professional associations, Royal Colleges, research councils and research institutes. The Inquiry also commissioned a series of scientific papers on key policy areas and population groups (on housing and on older people, for example). These papers, along with other evidence submitted to the Inquiry, were reviewed by a separate evaluation group, which again underlined the dearth of evaluated interventions addressing the 'upstream' and broader influences on health inequalities.

39 recommendations
Drawing on this large body of evidence, the Inquiry identified 39 areas where policy leverage should be exerted and could be expected to yield health gain. The 39 recommendations target influences on health inequalities over which government - at national, regional and local levels - exercises a considerable degree of direct control. There are recommendations relating to macro-level influences on health inequalities (like the distribution of income and employment), intermediate influences (like the quality of housing and the work environment) and individual factors (like exercise) (Figure 3). The recommendations seek to address not only socio-economic inequalities, but also gender and ethnic inequalities in health. The underlying message is for 'a broad front approach': a package of policies that target these levels of influence in a concerted and co-ordinated way.

Figure 3: three examples of recommendations of the Independent Inquiry

• uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them and which narrow the gap between their standards of living and average living standards;
• further measures to improve the nutrition provided at school, including the promotion of school food policies, the development of budgeting and cooking skills, the preservation of free school meal entitlement, the provision of free school fruit and the restriction of less healthy food;
• the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children.

As one example, policies designed to tackle socio-economic inequalities in access to healthy food include a review of the Common Agricultural Policy's impact on health and health inequalities, policies to improve access to outlets selling low-cost healthy foods and measures to improve nutrition in schools and to improve the living standards of households on social security benefits.

'A broad front approach reflects scientific evidence that health inequalities are the outcome of causal chains which run back into and from the basic structure of society. Such an approach is necessary because many of the factors are inter-related. It is likely to be less effective to focus solely on one point if complementary action is not in place which influences a linked factor in another area. Policies need to be both 'upstream' and 'downstream.''
Independent Inquiry into Inequalities in Health, 1998, p.7.

National targets for reducing health inequalities are not included in the Inquiry's policy package. While it recognised that target-setting is an important area for policy development, it was advised that 'consideration of this issue was not within the Inquiry's remit'.12 Nonetheless, the Inquiry considers that its policy agenda, if implemented, will have 'a major beneficial impact on inequalities in health'.(13)

Key policy priorities
Reflecting its emphasis on a broad-front approach, the Inquiry does not rank its 39 recommendations in order of importance. However, three policy commitments are identified as crucial to the success of any concerted national strategy to reduce health inequalities. It recommends that:

• all policies should be evaluated in terms of their impact on health inequalities and formulated to reduce such inequalities;
• the health of families with children should be given high priority to reduce health inequalities now and in the future;
• action is needed to reduce income inequalities and improve the living standards of poor households.

Conclusion
The publication of the report of the Independent Inquiry and the anticipated publication of the White Papers on public health are likely to fuel the debate within the research and policy community about how to reduce health inequalities. Reductions in health inequalities represent downstream outcomes which require strategies which target upstream influences. How to equalise access to the determinants of good health is likely to be a question framed by disagreements about the evidence, both on causal pathways and on effective solutions. It is likely to be a debate which turns, too, on questions of cost. What level of investment can and should the UK afford to reduce what are widely regarded as unacceptable inequalities in the health opportunities of its people? While often posed as an economic question, it is also and ultimately a political one. As the debate gathers momentum, it is therefore important that there is wider debate, in which both the public and policy community are involved, about how to equalise the chances of health and the risks of death between rich and poor in the UK.

Hilary Graham is Director of the ESRC Health Variations Programme, Lancaster University and was a member of the Scientific Advisory Group of the Independent Inquiry. Michael Marmot and Margaret Whitehead, who both have projects within the Health Variations Programme, were also members of the Scientific Advisory Group. The views expressed in this article are given in a personal capacity.

The full report of the Independent Inquiry into Inequalities in Health, including its recommendations, is available on the Stationery Office website (http://www.official-documents.co.uk). A shorter version is available on the Department of Health website (http://193.32.28.83/ih/press.htm).

References:
1. Independent Inquiry into Inequalities in Health (1998) Report of the Independent Inquiry into Inequalities in Health, London : The Stationery Office.
2. Hills, J. (1998) Income and Wealth: the Latest Evidence, York : Joseph Rowntree Foundation.
3. Drever, F. and Whitehead, M. (eds.) (1997) Health Inequalities, London : The Stationery Office.
4. Department of Health and Social Services (1997) Well into 2000: A Positive Agenda for Health and Wellbeing, Belfast : The Stationery Office.
5. Secretary of State for Health (1998) Our Healthier Nation: A Contract for Health, London : The Stationery Office.
6. Scottish Office Department of Health (1998) Working Together for a Healthier Scotland: A Consultation Document, Edinburgh : The Stationery Office.
7. Secretary of State for Wales (1998) Better Health Better Wales: A Consultative Paper, Cardiff : Welsh Office.
8. Department of Health (1980) Report of the Working Group on Inequalities in Health (The Black Report), London : Department of Health.
9. Editorial (1980) British Medical Journal, 20 December, p.1663.
10. Department of Health (1995) Variations in Health: What Can the Department of Health and the NHS Do? London : Department of Health.
11. Ibid. p.29.
12. Ibid. p.3.
13. Ibid. Preface v.