A major problem
Health inequalities in the UK are real. For example:
- Men in affluent Kensington and Chelsea live, on average, 11 years longer than their counterparts in Glasgow.
- Women in affluent Richmond upon Thames can expect to enjoy an average of 18 more years of good health than their counterparts in Tower Hamlets.
These health inequalities are also increasing. For instance:
- The Office for National Statistics (ONS) has reported that health divisions are increasing in England and Wales
- The North South health divide is wider than it has been in forty years
This matters for families, communities, the economy and the NHS. So, how can we best tackle these health inequalities? First, we need to understand what is causing them.
Our assessment is that financial circumstances (income and assets) combine with environmental factors (from quality of housing to pollution to an obesogenic environment) and the interconnection between what is going on in our minds, our bodies and our relationships with those around us. Let’s take each in turn:
If you’re well off financially you can afford to buy things that might keep you healthy – from fresh fruit and vegetables to decent housing to gym membership. If you have less money you’re less likely to have enough to spend on these options.
This is arguably a bigger issue in the UK than in many other European countries. For example:
- The Food Foundation reports that across much of mainland Europe, the healthy choice is often the cheaper one, meaning the UK is unusual in unhealthy choices often being cheaper.
- There’s a shortage of affordable housing in the UK. In 2018 the European Federation of National Organisations Working with the Homeless (Feantsa) reported that the cost of a home for the lowest earners has risen faster in Britain than anywhere in western Europe.
With basics like heathy food and decent accommodation often more expensive in the UK it is hardly surprising if those on low incomes are struggling.
The growing pay divide between those at the bottom and top of organisations has often been commented on but not yet successfully addressed here in the UK and so is continuing to fuel social inequality. For example, the Financial Times reports that in 2018 top UK chiefs were paid 117 times more than the average worker. And Statista reports that the gap in CEO versus employee pay is higher in the UK than in most other countries, including Germany, Canada and the Netherlands.
Action needed to address financial inequality
These measures alone will not bring an end to financial inequality and, through this, health inequality. However, they will provide useful first steps and send an important signal.
Significant economic forces and major players, accumulating over recent years, have created an environment which is both obesogenic and polluting, as well as working environments which are often not conducive to good physical or mental health – disproportionately affecting the health of people in deprived areas.
For example, people in low income families are more likely to live in areas vulnerable to air pollution – which is estimated to cause some 40,000 deaths a year, caused in particular by vehicle and industrial emissions. Meanwhile research in China suggests that proximity to more green space (typically more common in affluent areas) is associated with increased life expectancy. This may be because it encourages exercise, is good for mental health and reduces exposure to air pollution.
People on low incomes are also often more likely to be employed in working environments or on working conditions that increase health risks. For example, they are more likely to be doing shift work, which is known to increase health risks. They are also less likely to have well-designed jobs and working environments, control and autonomy, and jobs with meaning and purpose – all factors influencing health at work.
A third and important aspect is our obesogenic environment, where food is available 24/7, portion sizes have grown, and processed food high in sugar, salt and fat is heavily and persuasively marketed (as well as an environment in which opportunities for physical activity, in particular through work, have declined). This matters because, according to the NHS, obesity increases the risk of type 2 diabetes, coronary heart disease, some types of cancer, stroke and depression – and because obesity is more prevalent in deprived areas.
Action needed to tackle environmental disadvantages
After more than 30 years researching the influence of status on health and longevity, Professor Sir Michael Marmot concluded that social inequality (status) is even more damaging to our health than poverty. The experience of low status and inequality – being low status, feeling low status and being made to feel low status – has a significant and detrimental effect on people’s lives and health.
This may help explain why people in deprived areas seem more likely to smoke, abuse alcohol and become obese – all health risks. Some studies suggest this is because they are more stressed due to their situation and see smoking, alcohol and comfort eating as ways of managing that stress. This appears to be corroborated by the 2014 Health Survey of England, which found that 17% of the poorest women took antidepressants compared with 7% of the richest.
Action needed to tackle psychosocial factors
A cycle of deprivation
The early years of life, from conception onwards, can have a long-term influence on both physical and mental health. For example, children whose mothers eat ‘junk food’ during pregnancy, don’t breastfeed, don’t provide healthy diets during childhood, use food to pacify children and are themselves obese are more likely to have children who are obese. This helps explain why the prevalence of childhood obesity is sometimes over twice as high in the most deprived areas as in the least deprived areas.
Similarly, we know that children who have been abused or neglected as children or who have grown up in dysfunctional families (for example where drug or alcohol abuse or criminality are common) are more likely to experience diagnosed mental health conditions as they get older.
One further aspect of deprivation relates to education and language development. Actuaries, who advise the insurance industry on how long pensioners are likely to live, know the health benefits of education. As the Institute and Faculty of Actuaries has noted: ‘The evidence that education acts directly to improve mortality independent of socio-economic status is said to be under-appreciated outside of demography’.
However, people from disadvantaged backgrounds face particular obstacles when it comes to education
- Poor children typically start school already behind their more privileged peers because they have been exposed to a narrower range of language and educational experiences.
- This disadvantage is compounded during their years at school by a range of parental interventions in wealthier families, which may even include arranging private education or private tuition.
- Education funding in the UK is heavily focused on provision for young people, through schools and universities, with minimal funding for lifelong learning – thereby limiting opportunities for people from disadvantaged backgrounds to catch up when they become adults.
This educational disparity between rich and poor is particularly important, given the potential of education to help people progress beyond their socio-economic origins – and also a range of evidence that more education is associated with better long-term health, including helping delay the onset of dementia.
However, research suggests that parents can help their children overcome some of the educational disadvantage if they are aware of the importance of language development and willing and able to encourage this in their children.
Interventions with mothers-to-be are likely to be the most effective way of breaking the cycle. This is a time when women tend to be more open to health-related advice, for themselves and their children-to-be. Encouraging healthy diets can prevent childhood obesity while encouraging language development can help children arrive at school better placed to learn, to develop more of their potential through education and access the improved health associated with higher levels of education.
Action needed to tackle the cycle of deprivation
Recognise what the NHS does – and what it doesn’t
Because the NHS is called the National Health Service, there’s an assumption that health is what the NHS provides. In fact, what the NHS is overwhelmingly resourced to provide, is treatment for accident and illness i.e. it is a National Medical Service. This is an important service but it is not the same as a health service i.e. a service which promotes and supports the nation’s health in a pro-active rather than reactive way.
This matters when it comes to health inequalities, because socio-economic factors may have more impact on health outcomes than medical treatment – suggesting the need to implement long- term policies to reduce social inequality.
The Pareto principle (or 80/20 rule) is probably a useful guide here i.e. investing 20% of the health budget in public health is likely to achieve 80% of the desired health outcomes longer term, with 80% invested in the NHS, to restore to health those who have experienced accident or illness.
Health action - to complement the NHS’s medical role
A Third Way
Attempts to tackle health inequality have tended to be limited by political ideology.
For example, Conservative politicians tend to assume that market solutions are most effective. So providing consumers with health information, including through health apps, to enable them to make informed decisions, is an important way forward. Unfortunately, Public Health England reports that 42% of working age adults are unable to understand and make use of everyday health information, rising to 61% when numeracy skills are also required for comprehension.
Conservative politicians also tend to assume that people need to take personal responsibility for their own health. For instance, in an article in The Spectator in 2020, associate editor Rod Little argued that ‘lardbuckets’ shouldn’t be consuming so much ‘crap’ and would benefit from a bit of fat-shaming. Personal responsibility is a genuine issue – but so too is corporate responsibility. Should we only single out for censure those who consume ‘crap’ and not those who manufacture, market and distribute it?
Labour politicians also tend to bring their own ideological perspective. There’s a tendency to downplay individual responsibility and see socio-economic factors as not simply having a strong influence on health but actually ‘determining’ it. Whilst this recognises the significant role socio-economic factors play it potentially underestimates both human potential and agency, seeing people in deprived areas as ‘victims’ to be supported – in particular through action by the State, for example through a combination of the welfare system to provide support and regulation to rein in businesses whose products increase health risks. While well-intentioned this approach doesn't always achieve the degree of success anticipated.
Both ideological approaches tend to underestimate a third dimension i.e. that we are social animals, influenced by our relationships with our immediate peers - and therefore the importance of communities. As recent books like The Third Pillar and Alienated America have insightfully identified, societies ignore the importance of active communities at their peril.
In practice, when tackling childhood obesity in deprived areas for example, in a number of different countries community- based initiatives have so far proved most effective (as with the JOGG programme in the Netherlands). While, in a broader health context, as the C2 Beacon project in Falmouth has demonstrated, community involvement is key to developing healthy communities. Engaging with and empowering local stakeholders and children/families within communities can help achieve inclusive, sustainable lifestyle and behaviour change, adapted to local contexts and taking account of existing social, environmental and cultural factors.
Action to support a Third Way
Michael Baber March 2021