TACKLING HEALTH INEQUALITIES

• The COVID-19 pandemic has thrown the issue of health inequalities into sharp focus and created an imperative for the NHS to deliver a step-change in how it cares for diverse and marginalised communities. This briefing reflects the key messages from a joint NHS Confederation and Association of the British Pharmaceutical Industry roundtable on the tangible approaches that could be taken to tackle the greatest societal challenge of our age.


Summary of the Cross-Cutting Review on Health Inequalities
The problem 1.
This country has seen increased prosperity and reductions in mortality over the last 20 years.However, inequalities in health outcomes persist, for example between socially disadvantaged and affluent sections of the population, males and females, and people from different ethnic groups.Many of these gaps are large and in some cases the gaps are wider now than 20 years ago.Health inequalities affect people at all stages of life and across different parts of the country.There are wide geographical variations in health status, reflecting the multiple problems of material disadvantage facing some communities.These differences begin at conception and continue throughout life.Babies born to poorer families are more likely to be born prematurely, are at greater risk of infant mortality and have a greater likelihood of poverty, impaired development and chronic disease in later life.This sets up an inter-generational cycle of health inequalities.

2.
Observational data suggest that an individual's risk of developing ill-health and dying are related in part to the circumstances of the previous generation.If so, then intervening before and during pregnancy and early in life should improve health.Data from actual intervention studies bear this out.An increasing amount of evidence, from the US and elsewhere, shows overwhelmingly that early intervention makes a difference.The earlier, the more intensive and the greater the quality of intervention the greater likelihood there is of long term, sustainable success.Early investment programmes can produce significant long and short term benefits for children in terms of improved health, improved social and emotional development and improved educational attainment.

Figure 1 Key facts: The problem of health inequalities and its inter-generational cycle
• In Manchester, boys can expect to live almost eight years fewer, and girls almost seven years fewer than their contemporaries in Kensington, Chelsea and Westminster.
• Life expectancy for males in social class V is over 7 years less than for professional social classes: 71.1 years compared with 78.5 years.For women the gap is over 5.5 years.
• Some populations in this country have the same levels of early death as the national average occurring in the 1950s.
• Babies with fathers in social classes IV and V have a birthweight that is on average 130 grams lower than that of babies with fathers in classes I and II.Low birthweight is closely associated with death in infancy, as well as being associated with coronary heart disease (CHD), diabetes and hypertension in later life.
• Research shows that lower birthweight and father's social class can both increase your chance of dying of CHD over and above the impact of your own income and social class.
• An analysis of over 100 local education authority areas found educational attainment at age 15-16 to be significantly associated with both CHD and infant mortality.

3.
Health inequalities follow a social gradient, with the health gap increasing steadily with poorer social class.Because of this gradient, and the distribution of the population in the different social groups, analysis in the Review shows that interventions must reach more than the most deprived areas and the most disadvantaged, socially excluded populations to meet the national targets and make progress on health inequalities more generally.It will be necessary to achieve change in all the manual social groups and to tackle pockets of deprivation in all parts of the country.

4.
The Cross-Cutting Review on Health Inequalities ('the Review') was established to address this challenge.The Review has, for the first time, brought together Ministers and officials from across Government departments and from local government, along with academic experts, to consider how better to match existing resources to health need and to develop a long-term strategy to narrow the health gap.The high level summary of this strategy is set out in Annex A. The Review established an Inter-Departmental Group (IDG) at official level, and the Departments involved are shown at Annex B.
The terms of reference of the Review are set out in full in Annex C.

5.
The work of the Review also highlighted the importance of local community involvement in action to tackle health inequalities, if interventions are to have a long-term and sustainable impact.The approach of the Review has been that it should set the strategic direction and then make recommendations for structures which will enable and empower local communities to tackle health inequalities effectively.The need for partnership, across Government, with local government and the NHS, between Government and local communities, and within local communities, has been a strong theme of the Review and is essential for such a complex and cross-cutting issue.
The evidence base

6.
The causes, risk factors and impact of differences in health status are inherently complex.Health inequalities range across a number of dimensions: by socio-economic class and by geographical area; by ethnicity, age and gender.These risks of early death and ill health have a different impact at different stages of the life course and appear to be clustered in some geographical areas and around individuals in identifiable groups.Furthermore, health inequalities cross the generations, significantly affecting the life chances and quality of life not only of individuals, but of their children and grandchildren.

7.
The Review considered the evidence base for health inequalities and effective interventions to narrow the health gap.A summary of the evidence of the gaps in health status is set out in Annex D. A full discussion of the approach and analysis of the Review are set out in a longer version of this summary available at www.doh.gov.uk/healthinequalities/ccsrsummaryreport 8.
In addition, analysis of the evidence identified the following characteristics of successful approaches to improving health, particularly among the most disadvantaged.The Review considered these alongside a range of other evidence, as well as advice from the DH consultation process and practical experience derived from Sure Start, Health Action Zones and other relevant programmes.These findings should underpin all the interventions identified by the Review.
A long-term strategy for tackling health inequaliites

9.
The Review has developed a long-term strategy to tackle health inequalities, setting out what needs to be achieved through concerted effort from a wide range of individuals and organisations including a range of Government departments, the NHS, local government, the community, voluntary and business sectors.The approach is one of mainstreaming work on health inequalities so that it is at the heart of Government policies rather than a marginal "add on".The theme is one of partnership, across Government and between Government and local communities.This approach should ensure long-term sustainable change, making tackling inequalities an integral part of policy development and implementation across the board.Following the conclusion of the Review, a cross-Government Delivery Plan is being developed which will be taken forward by proposed new Ministerial and official structures.This plan will focus on the immediate spending review period to March 2006, but action will be necessary beyond this period if it is to have an impact on this complex and deep rooted problem.

10.
Assessing the impact of reductions in inequalities on health service use is complex.Many aspects of health inequality show adverse (widening) trends, which the Government is committed to reversing.Within the health service, activity will lead to improved access and better quality services for disadvantaged groups -particularly in relation to preventive services.
Top priorities for meeting the national health inequalities targets 11.
In addition to tackling health inequalities across the board, the Review had a particular focus on meeting the two national health inequalities targets, announced by the Secretary of State for Health in 2001, to narrow the gap in life expectancy by area and to reduce the difference in infant mortality across social classes by 2010.This is a relatively short period in which to expect change in such persistent and longterm trends.Analysis of available evidence on the problem, and on effective and promising interventions which will impact in this timeframe, showed the most significant interventions which will support the delivery of these targets by 2010 are as follows.

Figure 2 Key Findings on Successful Interventions
• Local assessment of needs, especially involving local people in the research process itself.
• Mechanisms that enable organisations to work together -ensuring dialogue, contact and commitment.
• Representation of local people within planning and management arrangements -the greater the level of involvement, the larger the impact.
• Design of specific initiatives with target groups to ensure that they are acceptable (i.e.culturally and educationally appropriate), and that they work through settings that are accessible and appropriate.
• Training and support for volunteers, peer educators and local networks, thus ensuring maximum benefit from community-based initiatives.
• Visibility of political support and commitment.
• Re-orientation of resource allocation to enable systematic investment in community-based programmes.
• Policy development and implementation that brings about wider changes in organisational priorities and policies, driven by community-based approaches.
• Increased flexibility of organisations, so supporting increased delegation and a more responsive approach.
Interventions likely to make the major impact on achievement of the life expectancy target are: • Reducing smoking in manual social groups through extended smoking cessation services, complementary tobacco education campaigns and other supporting interventions.

•
Prevention and effective management of other risk factors in primary care (e.g. through early identification and intervention on poor diet, physical inactivity, obesity and hypertension through lifestyle and therapeutic interventions, including use of statins and anti-hypertensives according to need).

•
Environmental improvements to improve housing quality to tackle cold and dampness and increase safety at home (e.g.smoke alarms, hand rails), and to prevent road accidents among old and young road users.

•
Targeting over-50s where the greatest short-term impact on life expectancy will be made.

13.
Interventions likely to make the major impact on the infant mortality target and on early years development are: • Building on Sure Start to improve early years support in disadvantaged areas.

•
Reducing smoking in pregnancy.

•
Preventing teenage pregnancy, and tackling its causes and effects.
• Improvements in housing conditions for children in disadvantaged areas.
• Other forms of early intervention for the NHS, for example to increase immunisation rates and breastfeeding, improve diet, family support and education about infant sleeping position.

14.
Health inequalities cannot be effectively tackled by NHS interventions alone.The Review has drawn up a cross-Government strategy for reducing health inequalities that identifies the key interventions needed.
It is clear that a cross-Government and cross-sector approach at local as well as national level is essential.

Key themes of the review
15.
The work of the Review highlighted the cross-cutting nature of the determinants of health inequalities.It identified the following themes from the analysis of the evidence.These informed the development of the long-term strategy.

Breaking the Cycle of Inequalities
16.
There is a strong correlation between health inequalities and poverty and deprivation that begins at birth and continues throughout life.A child's health is significantly influenced by their parents' socioeconomic status.The Government's policies for tackling poverty and deprivation have a key role to play in narrowing the health gap.Education and employment have been identified as fundamental determinants of health inequalities, and the Review has highlighted the importance of reducing the differences in the early years' development of children in order to ensure that children from low-income families are able to take full advantage of opportunities at school and subsequently at work.Teenage pregnancy is strongly associated with deprivation, and there are associated risks for the health of the baby.
Tackling the major killers 17.
The Review has identified strong social gradients in the incidence of the major killers and risk of injury, together with significant differences between ethnic groups.Differences in cancer and circulatory diseases account for the greatest part of the potential improvement in overall life expectancy if they could be eliminated: of the gap between the fifth of geographical areas with the lowest life expectancy and the national average, an estimated 20 per cent is due to cancer and 40 per cent is due to circulatory diseases.Smoking is the single most significant causal factor for the socio-economic differences in the incidence of cancer and heart disease.However, also important are physical activity and nutrition, with a continued epidemic of heart disease forecast as a result of current trends in inactivity and unhealthy diet.
There are also inequalities in health for people in black and minority ethnic groups in relation to cardiovascular disease, diabetes and cancer.Policies that give people the skills, information and support to make and sustain healthy lifestyle choices are therefore important.In addition, there is evidence of significant inequalities in the incidence of accidents and injuries, especially among children from lowincome families.

Figure 3 Key information -Breaking the cycle of health inequalities
• education plays a key role in this cycle.A significant association has been demonstrated between educational attainment at age 15-16 and CHD.Finishing full-time education at an early age is associated with higher subsequent mortality rates.Educational qualifications are a major determinant of labour market position, and influence income, housing and other material resources; • parental employment affects their children's future health: father's social class and birthweight can both increase their chance of dying of CHD over and above the impact of their own income and social class; • if smoking in pregnancy fell by 10% (from 18% to 16.2%), it is estimated that the average infant birthweight would rise by just over 3.5 grams.Low birthweight is associated with increased mortality and morbidity in the first year of life, and throughout childhood; • if no mothers smoked, the average birthweight would rise by an estimated 36 grams; • smoking in pregnancy is four times more prevalent among women in households in social class V than those in social class I. Teenage mothers are the most likely of all age groups to smoke in pregnancy -nearly two thirds of under 20s smoke before pregnancy and almost a half during it; • the effect of halving the number of teenage births would by itself achieve an estimated 10% of the target reduction in infant mortality rates (the infant mortality rate for teenage mothers is 60% higher than for older mothers); • the risk of becoming a teenage mother is almost ten times higher for a girl whose family is in social class V than those in social class I; • the infant mortality rate among children in social class V in 1998-2000 was double that for social class I, with rates rising from 4 deaths per 1000 live births in social class I to 5.4 in social class III (manual), 6.2 in social class IV and 8.1 in social class V.For lone parents the rate was 7.6 deaths per 1,000 live births.

18.
There is evidence that those in greatest need of public services often have the lowest levels of use and the poorest access to these services.This is greatly compounded by poor access to public transport and few alternative transport options.Access and use of the NHS, local authority services, employment services, housing and other social services and community facilities can affect health inequalities.For example, for black and minority ethnic groups, service providers' insensitivity to cultural, religious and language issues and lack of cultural competence can have an impact on the take up of services and facilities.The same applies for insensitivity to gender differences and people with physical and learning disabilities in the take up of services and service preferences.Some vulnerable groups have difficulty accessing mainstream services too, and need targeted programmes, as set out below.

Figure 4 Key information -Tackling the major killers
• smoking is responsible for the major part of mortality differentials by social class in middle age.Amongst males aged 35-69, it has been estimated that, if smoking rates among social class V were the same as those in social class I, this would remove around half of the inequality; • the death rate from CHD is three times higher among unskilled manual men of working age than among professional men.The death rate in men under 65 years is 1.6 times higher in the North West Region than in the South East.In Manchester, the death rate for people under 65 years is over three times higher than in Kingston & Richmond: 69.3 and 20.6 per 100,000 respectively in 1998-2000.Emerging evidence suggests that a cause of CHD may be work-related stress, particularly where there is high demand and low control at work.CHD in civil servants has been found by the Whitehall II studies to be more prevalent in the lower socio-economic groups; • obesity is more prevalent in lower social classes -28% of women in social class V are obese, compared to 14% in social class I (England, 1998); • lung cancer incidence is higher in the north than the south of England, and higher in urban than in rural areas; • manual workers make up 42% of the workforce, but account for 72% of reportable work-related injuries; • children in social class V are five times as likely to suffer accidental death than their peers in social class I, 83 and 16 per 100,000 respectively; • residential fire deaths for children are 15 times greater for children in social class V compared to those in social class I; • an unskilled working man was, at the time of the last Census, almost four times more likely to commit suicide than his professional counterpart.Rates in partly skilled and manual skilled workers were twice as high as the professional group; • the death rate from CHD is up to five times higher for people with diabetes.One in twenty people over 65 have diabetes.

19.
Many areas across the country suffer from multiple deprivation, and the links between area-based deprivation and health inequalities are strong.The Government's Neighbourhood Renewal Strategy is vital for tackling the area based influences of ill-health, and there is an urgent need for improvements in the 88 deprived areas receiving the Neighbourhood Renewal Fund.However, there are pockets of deprivation right across the country and health inequalities will need to be tackled in all these areas if the national targets are to be met.The Review made links to a parallel review by the Cabinet Office on Area Based Initiatives, through which it was agreed that Health Action Zones had done a great deal of innovative work in deprived areas, and that this should be mainstreamed to other parts of the NHS.

20.
Area based differences in health status are not simply a reflection of differences in health relating to social class.Rates of death among unskilled working men vary greatly between areas in the north and the south.A poor physical environment itself has a negative impact on health.Physical as well as mental health are influenced by the stress associated with living in neighbourhoods where the environment is seen as threatening, where the quality of the housing is poor and transport facilities are lacking.In addition it can be difficult for businesses to set themselves up in areas where crime is likely to be high, or for public services to attract staff.This is particularly true of the NHS where access to, and the quality of, primary health care in deprived areas is often significantly below that available elsewhere.

21.
Evidence of effective interventions to improve health, particularly among the most disadvantaged, shows the importance of building partnerships and developing community-based approaches.The social support networks, relationships, and levels of participation and trust in a community are important influences on the health of individuals in that community and on local capacity to address health problems.Interventions to improve health work best with pro-active local participation in their design and implementation.

Figure 5 Key information -Improving Access
• fewer GPs tend to serve the most disadvantaged communities: for example, in October 2000, whole time equivalent general practitioners (including registrars) numbered around 45 per 100,000 weighted population in Sunderland, but 69 per 100,000 in North Yorkshire.
• rates of hospital admission for coronary artery bypass grafts and coronary angioplasty are not generally higher in areas with the greatest need (i.e.those in areas with the highest CHD mortality).
• analysis of the fourth National Survey of Morbidity in General Practice showed that the rates of consultation for preventive care were 37% lower in men aged 16-24 years from social classes IV/V than for those in social classes I/II.For men aged 25-39 years, preventive care consultation rates were 31% lower.
• women of Bangladeshi origin are less than half as likely as those in the general population to take up invitations to cervical cancer screening.
• of those without access to a car, 27% face difficulties travelling to hospital, 13% find accessing primary care difficult, and 16% find access to supermarkets hard.
• 40% of job seekers say that their job search was limited because of the costs involved.For the majority this was to do with transport.
• 47% of 16 to 18 year old students said they found their transport costs hard to meet.On average, annual transport costs were £370 a year.
• older people, particularly very old people, do not get fair access to health and social care services.The Acheson Report found that lack of access to transport is experienced disproportionately by older people, limiting their access to goods, services, opportunities and social contacts.

23.
Tackling the causes of health inequalities requires action at both national and local level, involving Government Departments, NHS organisations and local authorities.To date, health inequalities have been seen as primarily an issue for the NHS.However, addressing the underlying causes requires co-ordinated action, bringing together health services with a range of other interventions and programmes.The aim of the Review has been to set the strategic direction for action across Government, in local government and for local communities and services.To be effective, interventions to tackle health inequalities need to have leadership at the local level and be accountable to local communities.The intention is to put in place delivery mechanisms and structures to empower those at local level to design and carry out the interventions most effective and appropriate for their communities to deliver the strategy.

24.
The Review was particularly concerned to: • Ensure that health inequalities remained a Public Service Agreement (PSA) target for the Department of Health, and that DH should take the lead on the issue across Government  • 57% of the 'fuel poor' are aged 60 and over; • unmodernised homes have high heating costs and contribute to fuel poverty.Cold housing increases the likelihood of ill health (illnesses such as influenza, heart disease and strokes are all exacerbated by the cold) and may contribute to the excess of winter deaths seen in older people and also to fuel poverty.Properties in poor condition are disproportionately occupied by single older people; • in the five years from 1994/5, the lowest 30% income households have spent over twice as much of their income proportionally on fuel than the average for all households and over three times that of the highest 30% income households; • poor housing design contributes to serious accidents, particularly in older people, and seemingly minor accidents which may have grave consequences; • of the 4,000 accidental deaths in the home in 1999, older people accounted for 47% (although only 16% of the population).Falls caused the largest number of fatal injuries in older people (62%), and are a major cause of disability; • the Acheson Report highlighted the fact that, compared to the national average, the mortality rates in people aged 60 to 74 who had been living in local authority rented accommodation showed a 16% excess; • the average life expectancy of rough sleepers is around 42 years of age; • the proportion of adults assessed as having a neurotic disorder was 80% higher in social class V than in social class I in 1993; • among adult prisoners of working age, 90% have a history of mental ill-health and/or substance misuse; • morbidity resulting from diabetes complications is three and a half times higher in social class V than social class I. Certain ethnic groups are more likely to develop diabetes and people in the most deprived fifth of the population are more likely to suffer diabetes.

•
Ensure strong cross-Government Ministerial drive and co-ordination by bringing oversight of the cross-Government Delivery Plan on health inequalities within the remit of the Cabinet's Domestic Affairs Sub-Committee on Social Exclusion and Regeneration (DA(SER)).
• Ensure effective joint working between primary care trusts (PCTs) and local authorities, along with other local partners and the community.This should include determining a single set of local priorities for health inequalities and working together in a coherent and co-ordinated way to tackle the different causes, with a clear focus on outcomes.The Review felt that existing or developing structures should be suitable for this purpose, particularly Local Strategic Partnerships.

•
Ensure the PSA targets for health inequalities are made a clear priority for the NHS and local government and are integrated into their mainstream planning, performance management and funding structures.These performance systems and structures include: - • PCTs and local authorities to be encouraged to make joint appointments of Directors of Public Health

25.
The Government is putting together a cross-Government Delivery Plan for tackling health inequalities, building on the work of the Review.This will set out the priorities for action across Government, including local government and in the NHS, in partnership with the community, voluntary and business sectors, and will be based on a mainstreaming approach to tackle the wider determinants of health.The cross-Government Delivery Plan will be published shortly.

Terms of Reference
In support of the Government's objective of narrowing the health gap in childhood and throughout life between socio-economic groups and between the most deprived areas and the rest of the country; and in particular to help ensure that the Government delivers its national health inequalities PSA targets for life expectancy and mortality of children under one year: 1) Developing the evidence base • building on consultation currently being undertaken by DH, to collate and evaluate the available evidence about the contribution that high quality public services across central and local government can make to tackling the causes of health inequalities; • to establish a map of available resources and public services that will help tackle the causes of health inequalities; • to identify the main obstacles arising from existing patterns of resourcing and service provision to delivery of the PSA health inequalities targets; 2) A strategy for delivery • in the light of the evidence base, to develop a cross-governmental strategy for tackling the causes of health inequalities, that will help ensure delivery of the PSA targets; • to make recommendations as necessary for better matching existing resources, and any proposed changes in departmental baselines in relevant areas, to health need in the NHS and across government; • to establish a basket of indicators for monitoring progress against the PSA targets.

Organisation of the review
The lead minister for the review will be the Minister for Public Health.She will co-ordinate work with colleagues from across government and with other stakeholders.

Terms of reference of the Cross-Cutting Review
This country has seen increased prosperity and reductions in mortality over the past 20 years, yet differences in health status have persisted between different groups in the population.Many of these gaps are large and in some cases the gaps are wider now than twenty years ago.Figure 8 summarises the extent and nature of this health gap, referring to different types of health inequality and different health indicators.A full discussion of the approach and analysis of the Review are set out in a longer version of this summary at www.doh.gov.uk/healthinequalitiesSome differences in health status are unavoidable, the consequence of genetic and biological differences • Children in social class V are five times as likely to suffer accidental death than their peers in social class I, 83 and 16 per 100,000 respectively.Children in social class V are five times more likely to be killed as pedestrians in road accidents than children in social class I.
• Residential fire deaths for children are 15 times greater for children in social class V compared to those in social class I.

and in different causes of death and ill-health
• The death rate from coronary heart disease is 3 times higher among unskilled manual men of working age than among professional men.The death rate in men under 65 years is 1.6 times higher in the North West Region than in the South East.In Manchester, the death rate for people under 65 years is over three times higher than in Kingston & Richmond: 69.3 and 20.6 per 100,000 respectively in 1998-2000.
• A woman in an affluent area is more likely to live for at least five years after a diagnosis of breast cancer than a woman in a deprived area (71% surviving for five years as compared with 63%).
• An unskilled working man was, at the time of the 1991 Census, almost four times more likely to commit suicide than his professional counterpart.Rates in partly skilled and manual skilled workers were twice as high as the professional group.
Figure 7 Key information -Specific Groups

Figure 8 A
Figure 8A gap in health status exists: between social groups • The difference in life expectancy at birth between men in social classes I and V widened from 5.5 years in 1972-6 to 7.4 years in 1997-9; average life expectancy in 1997-9 being 78.5 years in social class I and 71.1 years in social class V.For women this gap increased slightly from 5.3 years to 5.7 years over the same period.Both gaps have narrowed slightly over the 1990s.betweendifferent areas in the country• Male residents in Manchester can expect to live nearly 8 years fewer than those of Kensington, Chelsea and Westminster, and its female residents can expect to live nearly 7 years fewer (7.7 and 6.6 years respectively).between the population as a whole and different Black and minority ethnic groups • In 2000, infant mortality among babies of mothers born in Pakistan was 12.2 per 1000 live births, more than double the infant mortality rate for all babies.betweenmen and women • Men live, on average, about five years fewer than women (75.4 and 80.2 years respectively).throughout the lifespan, starting at birth • The infant mortality rate among children in social class V in 1998-2000 was double that for social class I, with rates rising from 4 deaths per 1000 live births in social class I to 5.4 in social class III (manual), 6.2 in social class IV and 8.1 in social class V.For lone parents the rate was 7.6 deaths per 1000 live births.
the Priorities and Planning Framework for the NHS, and the performance management by Strategic Health Authorities of achievement against these priorities;