Ten years after the Acheson Report, do we still need to be concerned about inequalities in health?

Abdus Samad 2902767

Introduction

Health Inequalities have been observed and reported in the UK since the ground breaking work of Willaim Farr on vital statistics first published in 1837. Health inequalities were identified by Rowntree (1901), Booth (1903), Titmuss (1943) and Tudor Hart (1988) among many others (Davey Smith et al. 2001a).

In 1977 the Labour party appointed Sir Douglas Black to chair a working group to review the evidence on health inequalities. The report was published in August 1980 under the Conservative Government. Key findings of the report were ‘large differentials in mortality and morbidity that favoured the higher social classes, and this issue hasn’t been addresses by the health or social services’ (Black, 1980). Black suggested a number of expensive policy recommendations and proposed the abolition of child poverty.

To implement Black’s recommendations would require the Government to increase taxation and public spending. These suggestions are clearly not in line with the New Right ideology, for that reason some commentators argue that the Tories refused to accept the existence of health inequalities.

Acheson Report 1998

Health inequalities came back to the forefront after the election of New Labour. The Government commissioned an independent inquiry in July 1997, overseen by a scientific advisory group chaired by Sir Donald Acheson. The remit was to review the latest evidence on inequalities and to identify priority areas for policy developments. The report published in November 1998 along with the Consultation paper Our Healthier Nation (DoH, 1998) showed the continued existence and renewed concerns for inequalities in health. The Acheson report made a number of recommendations, but identified three key priorities:

All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities.

A high priority should be given to the health of families with children.

Further steps should be taken to reduce income inequalities and improve the living standards of the poor (Acheson, 1998).

Policy Responses

The Government came to power with a commitment to “tackle inequalities and with recognition that they needed to be tackled through ‘joined up’ thinking across both central Government and local partnerships”. The Social Exclusion Unit was up, given the task of reporting directly to the Prime Ministers office with a remit to work across departmental boundaries.

LA’s and other actors were required to establish local strategic partnership and multi agency community strategies, Performance indicators and a range of national targets relating to health inequalities. Following the priority given in both the Black and Acheson report, child and family poverty and health were key policy priorities.

Within the health sector, the government published a public health strategy Saving Lives: Our Healthier Nation (Secretary of State for Health 1999) with an accompanying Reducing Health Inequalities: An Action Report (DoH 1999a) which laid out the range of government policies which addressed inequalities.

The NHS Plan (Secretary of State for health 1999) set out Public Service Agreement (PSA) and established two new national targets to reduce inequalities in life expectancy and infant mortality by 10% by 2010. Government also identified and focused on reducing health inequalities in 70 of the most deprived local authorities in England, ...

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The 2003 cross governmental strategy: Health Inequalities – A programme for action called for action against health determinants, focusing more on prevention and treatment.

All actors providing health care were expected to place inequalities in health at the centre of their performance management and planning. Emphasis was given on providing a more responsive service to those disadvantaged communities. Strategy included 82 cross governmental commitment and 12 cross governmental headline indicators (NAO, 2010). Health department set out targets to reduce Cancer, Stroke and Heart disease in the most deprived areas.

At the same time the government has implemented a major restructuring of the NHS in England with Primary Care trusts replacing health authorities as the major health sector player charged with tackling inequalities in health both through local strategic partnerships as well as actions within the NHS.

PSA Targets

Life expectancy has been increasing nationally, 77.9 years for men and 82 years for women. However, there have been little improvements in deprived areas with men expected to live till 75.8 years and women up to 80.4 (National Audit Office 2010). These figures make it clear that the government failed to meet the 2010 PSA target of reducing the gap by 10%.

The target for reducing all age/cause mortality rate by 2011 was 98 deaths per 100,000 for men and 58 for women. According to the National Audit Office, the gap for male reduced to 126 per 100,000 (2006-08) from 142 per 100,000 (1995-97). The gap for females increased to 78 deaths per 100,000 (2006-08) from 75 deaths (1995-97). Again, targets have not been met.

Following the publication of the 2003 cross government strategy on health inequalities, PCT’s and the NHS focused on implementing the 2000 NHS plan, strategic health authorities were reduced from 28 to 10 and PCT’s reduce to 150 by 2006, thus priority given to inequalities in health deteriorated (NAO, 2010).

Spearhead areas were criticised for having a direct action on specific areas and measuring outcomes. More then half of local authorities at the bottom quintile for life expectancy are outside of the 70 spearhead areas, and needed the same level of support as those in spearhead areas.

Even within targeted areas, resources allocated to tackling health inequalities are relatively small compared to mainstream spend in public. The government has emphasized the need to for neighbour hood renewal and other regeneration funds to be used ‘to bend mainstream services’. However there is little evidence of effective practice in doing this.

One of the NHS plan objectives was to increase the number of GP’s in spearhead areas. There are 5,700 more GP’s then ten years ago but 65% of spearhead PCT’s had very low level of coverage by GP’s compared to the national average.

Although the Acheson report strongly recommended reducing the gap in health inequalities, this never became a priority for the NHS until 2006. By 2007 PCT’s were required to report how improvements were being made on health inequalities.

Some argue the reverse has happened in terms of reducing the health inequality gaps between the rich and the poor. Actions taken to improve life expectancy have always benefited those who live in affluent areas as they are more likely to take up initiatives resulting in the gap getting even bigger.

Policy Effectiveness

A number of commentators have analysed policy on tackling health inequalities and concluded that it is beset with limitations and contradictions. The Acheson report has been criticized for a lack of prioritization, a weak evidence base, being inadequately concrete and uncosted (David Smith et al 2002). Scott-Samuel (2000) argues that constraints imposed by the government prevented radical recommendations to be implemented into policies such as a national inequality target. He further argues that policy responses were minimalist, providing a list of policy, action already taken in areas covered by Acheson report. As Macintyre (1999) points out, the breadth of the listed policy actions “means that it is very hard to discern in what ways the Acheson report has had any direct impact on government policy”. Policies did not make a distinction between poverty and inequality, thus Acheson’s point on income inequality has been ignored.

Different local agencies receive different ‘must do’s’ from central government; for example, the drive for academic attainment in the education sector does not encourage schools to engage in local partnerships to tackle the broader determinants of inequality.

Other aspect of government policy, particularly the short time scales within regeneration funding has to be spent, often militate against coherent interagency planning for long term service charge.

Within the NHS, the major central policy drivers focus on improving access and quality in secondary care and primary care rather then on tackling the wider determinants of health inequalities. Despite the government’s rhetorical commitment to tackling health inequalities, a number of commentators have suggested that there has been a de facto relegation of health inequalities in central priorities, resource allocation and performance management decisions (Exworthy et al. 2002). As Exworthy concludes, tackling health inequality is a policy priority for the government, but “local implementation is hampered by deficiencies in performance management, insufficient integration between policy sectors and contradictions between health inequalities and other policy imperatives”.

For many observers, key criterion is whether the government is successfully tackling poverty by redistributing wealth. Early evidence on this is unclear. Shaw et al. (1999) argues that although most families gained from the first three Labour budgets, overall the poorest did not improve their relative position. However Benzeval et al. (2000) found that the government had been successful in redistributing wealth, with the poorest income decile seeing almost a 10% increase in disposable income while the richest decile experienced a small decrease.

Conclusion

In this paper I aimed to analyse policies developed following the Acheson report, and examine if correct policies were implemented and if the objectives were achieved by the New Labour Government.

Having analysed the key health factors and trends that lie behind policy development, one is struck by the scale and complication of the demands placed on policy makers. Many factors that influence health inequality are beyond the control of health professionals and policy makers.

The 2010 Marmot review concluded that combating health inequalities is a matter of social justice with a massive economic benefit, necessary action should be taken across wider social determinants of health. Review estimates further £5.5 billion a year is spent on care associated with health inequalities.

Finally, to answer the question ‘do we still need to be concerned about inequalities in health?’ I will end with a quote from Townsend (1999) - an observer of the achievements and failures of successive governments on health inequalities policy:

“There is no doubt that the 1997 Labour government has given a greater priority than did the preceding governments of the 1980s and 1990s to inequalities in health. Equally, there is no doubt that a range of measures, including many which are external to healthcare policy, are now in play. This is welcome. But serious questions need to be raised: of the scale of action so far, of the effective management of the distribution of earnings and of disposable income, of the adequacy of income and of living standards generally of the many millions of people with no prospect of having paid employment. The new evidence presented (in The Widening Gap) suggests that action has been too limited, that redistribution has not been addressed, and that poverty levels in Britain are far too high for us to expect to see inequalities in health fall.”

Bibliography

Benzeval, M. Taylor, J. Judge, K. (2000) Evidance on the relationship between low incomeand poor health: Is the government doing enough? Fiscal studies, 21 (3): 375-99.

Davey Smith, G. Dorling, D. Mitchll, R. Shaw, M. (2002) Health Inequalities in Britain:Continuing increase up to the end of the 20th century, Journal of Epidemiology, 56: 434-5.

Exworthy, M. Berney, L. Powell, M. (2002) How great expectations in Westminster may be dashed locally: The local implementation of national policyon health inequalities, Policy & Politics.

Macintyre,S. (1999) Reducing health inequalities: an action report. Critical Public Health, 9, 347-350.

Shaw, M. Dorling, D. Gordon, D. Davey Smith, G. (1999)The widening gap: Health inequalities and Policies in Britain, Bristol: Policy Press

Townsend P. Foreword. In: Shaw M, Dorling D, Gordon D, Davey Smith G, eds. The widening gap health inequalities and policy in Britain. Bristol: The Policy Press, 1999, x-xvii.

Whitehead, M. Townsend, P. Davidson, (1992) N. Inequalities in Health: The Black Report and the Health Divide (Penguin Social Sciences) Penguin Books Ltd; New edition.

(Black, 1980).

Web Reference

Cross governmental strategy - Tackling Health Inequalities - A programme for action department of health 2003. Accessed 01/11/11

National Audit Office 2010 - NAO Report: Department of Health. Accessed 15/11/11

Our Healthier Nation 1998 – Department of Health. Accessed 18/11/11

Reducing Health Inequalities - An Action Report: Department of Health 1999. Accessed 20/11/11

Saving Lives: Our Healthier Nation - Secretary of State for Health 1999. Accessed 20/11/11

Scott-Samuel, A. (2000) EQUAL (Equity in Health Research and Development Unit) Department of Public Health, University of Liverpool. Accessed 20/11/11

The NHS Plan - Secretary of State for health 1999. Accessed 15/11/11

Tackling Health Inequalities – A programme for action 2003. Accessed 15/11/11

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