Health inequalities in Northern Ireland: are we failing?

The latest figures from the DHSSPS on health inequalities give us a chance to reassess thinking. As Paul McGill explains on pages 14-15 there are improvements in some areas but the gap between rich and poor and the consequent loss of life and health is a cause for serious concern. There is little point in having the data and saying we have a problem if we fail to do all we can to try and change things for the better.

Our first challenge is to convince a very wide range of stakeholders that change for the better can happen. Health inequalities vary over time and between societies. International data show rapid improvements in some countries and lack of improvement in others. It is clear that changes in the social and economic environment alongside public health action can do much to improve things. For example the gap in life expectancy between the bottom and top social groups in England and Wales grew from 5.5 years to 9.5 years in the two decades to the mid-1990s and then started to narrow.)

To make progress we need to understand the causes of health inequalities. The circumstances in which we live and work are of fundamental importance to our health. These circumstances are sometimes termed the social determinants of health and include income, housing, education, employment, transport and so on.

Researchers are coming up with new understanding of how social determinants affect health and particularly how they cause inequalities in health. It is the unfair and systematic distribution of these determinants that is causing persistent and profound differences in health. In other words the causes of health inequalities are inequalities in the social and economic determinants of health.

In a recent seminar arranged by Belfast Healthy Cities, Northern Ireland’s chief medical officer, Michael McBride, highlighted the ways in which social circumstances have such a profound effect on health. Scotland’s CMO, Harry Burns, told a compelling story of research linking the long term stress associated with deprivation with diseases such as heart disease and diabetes. We are beginning to see clearer evidence of how social circumstances affect disease mechanisms and this is important because it points to the actions and policy choices which are likely to be most effective.

There is a general political desire to improve health and wellbeing in Northern Ireland. So how does the draft Programme for Government shape up?

There seems to be a view that policy is a zero sum game and that we have to choose between a focus on economic growth or social development. This is patently not true. Of course economic development is important but it is a means to an end rather than an end in itself. As many leading international economists have said, economic growth alone will not bring improvements in health and education. We need policies across all sectors that are health and equity oriented.

This includes action on eradicating fuel poverty, improving social housing, protecting and promoting a sustainable environment

There is a widespread assumption that efforts to improve health will automatically reduce health inequalities. This is not the case. Improving health is not the same as reducing health inequalities. In fact if living standards continue to rise, effective policies will have to meet two criteria; improvements in health available to all AND a rate of improvement that increases all the way down the social ladder.

The publication of the anti-poverty strategy Lifetime Opportunities was welcome but in the absence of the long awaited action plan and no dedicated budget it seems as though this has fallen off the ladder.

World Development Reports have consistently shown that poverty is about opportunity, empowerment and dignity. People feel poor if they can’t do the things that are reasonable to expect in a society. Both poverty and inequality are strongly linked to poor health. As well as reducing absolute levels of poverty Lifetime Opportunities appeared to recognise that poverty is about more than money. The lack of action and apparent lack of commitment to this policy is deeply disappointing and will hamper any effort to reduce health inequalities.

Perhaps the most important area in which we can act to reduce inequalities is improving the life chances and opportunities of children. Evidence suggests so. This makes the recent rise in the level of child poverty all the more disturbing. The current inquiry into child poverty is a chance to make sure that politicians and policy makers know that there is wide support to end the appalling level of child poverty.

Shockingly, a recent Unicef report which assembled 40 indicators of child wellbeing in rich countries concluded that children in Britain and the US fared less well than the other 21 countries studied. Close analysis of this data (Pickett and Wilkinson 2007) shows that measures of child wellbeing are related to income inequality. What makes a difference to the wellbeing of children seems to depend more on reducing levels of inequality and reducing relative poverty than concentrating on further economic growth

The cross cutting public health strategy Investing for Health (IfH) will be reviewed in 2008. This is an important opportunity to raise the bar and show that we are seriously committed to improving public health in Northern Ireland. We will not do so without radical action to tackle inequalities. Whatever plans are made for this review we need to make sure that there is active involvement in decisions by communities and groups whose health and lives are most affected.

Fragmented and short-term approaches are ineffective and IfH needs to be more strongly linked to primary care. There is no question that the provision of comprehensive primary care is a key part of any successful effort to improve health. The worry is that financial pressure will lead to damaging cuts in planned expenditure on preventive services. We need to hold on to the principle of universal access to high quality care.

The recent Northern Ireland data show disturbingly poor levels of mental health among unskilled workers. We need to challenge the myth of the highly stressed wealthy executive. In fact it is far more stressful is to be in a low paid job or to be out of work and to experience the loss of control and autonomy this brings. Calls for better support and funding for mental health services are welcome and need to be tailored to ensure equity and to take into account the important impact on prevention and treatment of social circumstances.

We need to acknowledge local successes and the many organisations and initiatives which have tried to develop new ways of working, but must also recognise that setting up structures and partnerships is not enough without clearly articulated policies and their full implementation. We need a co-ordinated and comprehensive countrywide response.

Much of the debate about health inequalities is vague. Too often we aren’t clear about which inequality we are trying to change. Different dimensions of inequalities eg age, gender, socio-economic, disability need different responses.

We also need more research. The emphasis in much health research is on biological mechanisms. Vital as this is, we also need to research the social mechanisms that affect these biological processes. Investing in one without the other simply does not make sense. We need more multidisciplinary research, clearer reviews and dissemination of what works and better measures of both health and inequality

As Paul McGill has shown we need to examine the data carefully. Looking at area data is one thing, we also need to look at socio-economic groups. And there is a clear need to think about data and research on other forms of inequalities such as age, gender, ethnicity and disability. We need to look at absolute improvements or lack of improvement as well as summary figures. Not taking a wide and careful view means we can often miss the point.

Perhaps it would be clearer if rather than talking about reducing health inequalities we called for action to level up. We are fortunate in Northern Ireland to have systems that allow national data to be disaggregated by social group.

Health in an unequal society

Health inequalities are inhumane. In the end we all die but we should be indignant that those who are most disadvantaged are dying unnecessarily. The standards of health enjoyed by the best off should be attainable to all. And that is why I believe we must try to convince everyone in society that reducing health inequalities should be at the top of the agenda.

The driving force for action to level up health is social justice. Evidence and calls for action are not enough. We need political will and commitment for change – cross party support for health equity.