More to do: can anyone win the war on health inequalities?

Posted by Katherine Morgan at Fri, 12/03/2010 - 11:14am in Health Mandate commentary

As the end of the 2005-2010 Parliament approaches, and the political classes gear themselves up for the general election, each of the political parties' health teams will be looking to prove that they have the big ideas to take the NHS forward in a period of tight public finance but escalating public expectation.

In this short series of opinion pieces, Health Mandate's team of expert health policy consultants look at some of the big issues that will shape the political and the NHS landscape in the next parliament. Today's piece sees the Health Mandate team examine the challenges ahead in tackling health inequalities.

More to do: can anyone win the war on health inequalities?

Labour's success in improving the health of the poorest in society was always going to be a key test of its ability to deliver for its heartlands. For that reason alone, it is seen by many as a litmus test for the success of its health policies.

Yet the gap in health outcomes between the poorest in society and the population as a whole remains curiously intractable. The 2010 target for reducing inequalities in health outcomes is almost certain to be missed and the Audit Commission has found that the gap in teenage pregnancy, infant mortality and life expectancy has got wider.  Sir Michael Marmot's review 'Fair Society, Healthy Lives' has set out the scale of the challenge that remains.

For the Conservatives, health inequalities is also a key issue. Showing that they care about the health of the poorest in society is seen as an important change message.  However many Tory MPs - backbenchers and frontbenchers alike - remain angry in private that health funding has been diverted to relatively poorer (Labour voting) areas in an effort to improve health outcomes. Andrew Lansley has, perhaps intentionally, muddied the water by announcing his health premium. Although this promises more money for public health projects in poorer areas, it is not as simple as it seems.

The issue of health inequalities will be keenly contested at the election and both parties will be worried about candidates going off message. However, the real sleepless nights will be caused by trying to deliver on election promises to reduce health inequalities.

The Labour dilemma

In 1997, the prospects for reducing disparities in health outcomes looked relatively hopeful.

The Labour Government commissioned the 1998 Acheson Report which set out why inequalities mattered and made explicit the link between poverty and ill health.

The link with poverty of course plays to the tension at the heart of the Labour project. Health inequalities are partly caused by income inequalities and countries with fairer wealth distributions are as a whole happier, richer and healthier than those which are more unequal. Although this made intuitive sense to the Labour left, it was hardly a reassuring message to less traditional parts of the Blair coalition.

The impetus to tackle health inequalities was given a further boost by Derek Wanless' work on health. His projections only work if inequalities are addressed. Inequality in illness accounts for productivity losses of £31-33 billion per year, lost tax and higher welfare costs of £20-32 billion per year and additional NHS costs of £5.5 billion per year.

The result was a series of high profile targets to reduce inequalities in outcome, infant mortality and child poverty, spanning a range of Whitehall departments.

Progress has been made in improving health outcomes for the poorest, but outcomes for the rest of society have also improved. While there have been improvements in terms of lower rates of infant mortality and longer life expectancy across the population, the gap between disadvantaged groups and the rest of the population has remained.  Health inequalities are still substantial. It is now the case that people living in the poorest neighbourhoods are likely to die on average 7 years earlier than those in the richest. In London life expectancy falls by one year for every station you stop at from Westminster to Canning Town. The net result is that health inequalities remain a major cause of the UK's relatively poor performance on health outcomes in areas such as cancer and mental health.

Should Labour have done more to tackle inequalities? Were its targets ever achievable? Did it ever make the tough choices (such as reducing income inequalities) necessary to reduce the gap in health outcomes? These are questions that will be asked not only by academics, but also by the left of the Party as it seeks to reestablish clear red water between Labour and an Opposition seemingly intent on hugging the centre ground on health.

The Conservative dilemma

For the Conservatives, health inequalities is an issue where there has been a genuine shift in philosophical approach. It was, after all, the last Conservative Government which tried to downplay the Black Report and denied the very existence of health inequalities.

Gone are the days when Conservative spokesmen used all sorts of euphemisms to describe health inequalities , all in an attempt to deny their very existence. Andrew Lansley and his team are very clear (and very genuine) that health inequalities are very real, unacceptable and must be tackled.

Given the difficulties experienced by Labour in reducing health inequalities, the issue should be a fertile election theme for the Tories. Yet it also presents problems for Conservative Campaign Headquarters, as debates on health inequalities can quickly become bogged down in arguments about disparities in funding.

Many Conservatives candidates - including frontbenchers - remain angry at what they see as political attempts to divert resources away from older, Conservative voting populations towards poorer, Labour voting communities. Put simply, they feel that leafy Surrey lost out on increases to inner city Labour heartlands.

The resource allocation formula which determines how much funding each PCT receives is a quagmire for all politicians. Use it to focus resources on poor areas and they risk headlines about denying care to older people. Use it to support older people and they risk allegations of taking health funding away from the areas that need it most.

The Conservatives have proposed targeting public health resources on more deprived areas through introducing a health premium - a clear change message if ever there was one. Public health budgets, however, remain a very small part of the overall health budget and targeting these resources is very different from prioritising much larger NHS budgets in the same way.

Expect Labour election strategists to be watching closely for any hint that the Conservatives may tinker with the resource allocation formula.  This is something which the frontbench health team will come under pressure from party activists and 'save our hospital' campaigners to commit to, despite its potential toxicity in northern marginals. How the Party handles this issue, and the extent to which candidates are prepared to fall in behind the party line in the face of local pressures, will be an important test of the centrist strategy adopted on health, which has succeeded in whittling away Labour's historic poll lead on the issue.

Beyond the election

Although politicians' attention will remain focused on the battles which lie ahead in the next eight weeks, there are fundamental questions which will need to be addressed in the longer term if health inequalities are to be tackled.

With PCTs already feeling the financial squeeze, even before the slowdown in expenditure kicks in, local resources to tackle inequalities will be limited. Tackling the issues will require more than simply allocating money from an ever increasing budget. It will require difficult choices - including diverting resources away from the health issues which concern the articulate middle class. This will intensify the debate about the resource allocation formula as health service managers and clinicians mutter in the ears of local politicians about the inequities of the current system.

At a national level, tough choices will also be required. Will flagship Labour policies continue? Initiatives such as Healthy Start and public health campaigns will come under renewed financial pressure.

In the absence of money to throw at the problem, politicians could always try legislation or taxation as a mechanism for tackling ill health in the unhealthiest groups in society.  Further restrictions on smoking, measures to make alcohol more expensive and a 'fat tax' could all reduce unhealthy behavior, reduce inequalities and raise valuable revenue for the Exchequer. Whoever wins the election will also have a new Chief Medical Officer to work with. The extent to which this person decides to push the minimum alcohol pricing agenda may well be a defining health issue of the next parliament.

However, politicians  are naturally reluctant to be seen to 'nanny' or tax 'fun,' especially when it irritates swing voters, particularly at times when the electorate is already facing the financial pinch.

Will whoever wins the election be able to overcome a natural squeamishness about restricting personal liberty or taxing voters little pleasures in the name of tackling health inequalities? Will they dig deep to fund new programmes? Or will they have the political courage to face down the middle classes and divert existing resources to the cause? There will be lots of talk of 'nudges,' smart uses of behavioural economics and funding action through efficiencies, but winning the war on health inequalities is going to require some brave - and controversial - political decisions.

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