Reflections on the Development of Health Inequalities Policy in England

My focus in this article is England, principally because it is the country in which I was born, is where I live, and on which I know most about. Others have argued that the component countries of the United Kingdom (UK) have pursued a divergent path vis-à-vis health care policy over recent years, with Greer [8] arguing that while England has pursued a market approach, Scotland has focused on strengthening the role of professionals and Wales has tended to emphasise the importance of localism. With specific reference to health inequalities policy, however, others maintain that since 1997, all three mainland countries have highlighted the importance of reducing differentials in health (with all three conceptualising these inequalities as a policy problem relating specifically to the poor health of poor people), and, after analysing national policy statements, argue that there has been a surprising convergence across all three countries regarding the policy response to these inequalities [23]. Specifically, Smith et al. contend that in all three countries the emphasis placed on the wider determinants of health has lessened since at least 2003, and that placed on improving lifestyle behaviours, particularly smoking cessation, has increased. These authors also conclude that what they term ‘the medical model’ (by which they presumably mean individual interventions that are meant to have a ‘cause and effect’ impact on specific, targeted outcomes) has remained resilient to the advances of a more complex social model, which advocates a redistribution of the broader socioeconomic determinants of health and a strengthening of social cohesion as the best means to improve health equity (on this, see also [22]). However, there is a good political reason why governments pursue paths that are not always favoured by academics that some academics sometimes overlook; that is, in order to have a hope of being re-elected, governments often pursue approaches that are most favoured by the ‘median voter’.

As an aside, despite these days often being polled as the greatest ever Englishman, Churchill never won a majority of the popular vote at any general election, and my mother remembers him being roundly and soundly jeered whenever he appeared on the news at the local picture house towards the end of the war years.

Related to this, but moving away from a strict focus on health inequalities for one moment, it has become somewhat fashionable to claim that the health service impacts on population health only fractionally, and that most of our ‘health-related’ efforts should be geared towards the broader determinants of health. One ought to be careful with this line of argument. Irrespective of how much effort we put into preventive activities, people will always get sick and will want to be treated when that happens. Maybe my father’s ill health would have been prevented had his foundry been cleaner and had he never smoked. Maybe not. But what is clear is that the NHS has saved his life on numerous occasions over the past three decades, and that he is still here to tell (and tell, and tell) his tale. Had he lived in another time and/or place, he would have died decades ago.

Political windows are, however, easy to identify in retrospect. Therefore, one ought to be a little guarded about being too smug in suggesting what others should and should not have done.

Groopman [9] describes how this ailment can cause deaths if one is a medical doctor; fortunately, the arrogance of inexperience in health economists can cause at most, I hope, unrestrained annoyance. It can also be something of a chronic condition—the reader may be surprised to learn that arrogance in even experienced health economists is not uncommon, but is of course not a condition specific to the health economics community. Related to all this, another lesson that I have learned over the past decade is that one should never be ashamed of changing one’s mind. Indeed, Bertrand Russell thought that this was a sign of wisdom.

http://​www.​lho.​org.​uk/​HEALTH_​INEQUALITIES/​Health_​Inequalities_​Tool.​aspx

I live in one myself—Lewisham, which, at least for men, is on track to meet the life expectancy target, maybe because I moved there recently.

Scotland initially focussed on the health gap between the ‘top’ and the ‘bottom’, but eventually introduced health improvement targets for those at the bottom only [23].

Popay and Williams [22] and Williams [29] hold the view that individual behaviours cannot be understood in any meaningful way outside of the social context in which they are observed, and therefore that understanding the ‘well-spring’ of human agency is key to devising effective behaviour change policies. I agree that behaviours are fundamentally entwined with the social context, but I would maintain that behaviours can be and have (in terms of smoking cessation, for example) in the past been changed in health enhancing ways without a complete understanding of how structure and agency interact. Experimentation with behavioural interventions of the type briefly introduced below, even in the absence of full understanding of structure-agency interaction, is, I would maintain, therefore not unuseful, as it might lead to reductions in health inequalities that are both good for the individuals targeted, and good for the society in which we live. I should also note at this point that this article offers my perspective on the development of health inequalities policy, a perspective that inevitably reflects my background in health economics and behavioural economics and towards which I am only to aware that others, including Williams, will not concur. For sociological perspectives on health inequalities, the reader is advised to refer to Popay and Williams [22] and Williams [29].

A detailed discussion of the ethics of personal financial incentives is beyond the scope of this article. For ethical arguments against this form of intervention, see Szmukler [24]. For arguments in favour, in particular that they are a model of respectful, transparent exchange, see Burns [4].