Tackling health inequalities has become a key policy objective in the UK in recent years. While the 1980 Black Report received international attention but had a limited impact on national policy, the 1998 Acheson Independent Inquiry into Inequalities in Health has stimulated a wide-ranging policy response. For the first time ever, health inequalities have been made a priority for the National Health Service (NHS). Indeed, the principle that the “NHS will help keep people healthy and work to reduce health inequalities” was established as one of the service’s 10 core principles in the Labour government’sNHS Plan(DH, 2000).

The...

It is doubtful whether the original architects of the welfare state would have predicted that, at the start of the 21st century, health in the UK would be been even more unequal than it was in 1948, the year in which the National Health Service (NHS) was launched. It is, of course, generally accepted today that the health service has a relatively small role to play in the determination of health and well-being in the population. At the time, however, the formation of the NHS reflected a strong sense of social justice and a belief that health was a basic...

Since the publication in 1980 of the Black Report there has been a dramatic growth in research undertaken on health inequalities. This partly reflects the fact that variations in health lend themselves to analysis from a range of perspectives — social, geographical and historical (see Chapter One). Health variations are remarkably pervasive, being found at all stages of the lifecourse and pertaining to a very wide range of diseases and conditions, and have become an important focus of policy making. Consequently, research into health inequalities attracts interest from a wide range of disciplines, such as sociology, geography, psychology, epidemiology and medicine....

Chapter Two described the important academic legacy of the Black Report (1980), and also noted that, although the Report was coolly received by the Conservative government of the time, its recommendations have shaped the subsequent formulation of policy. Ironically, while the Black Report was criticised for the costs that it gave to its proposals, its successor, the Acheson Report, was criticised for not providing detailed costs. This, it was argued, would not provide government with sufficient information about the affordability and costeffectiveness of proposals to encourage a policy response. In fact, the Labour government can claim to have responded to...

In this main part of the book, we examine the pathways, policies and practice of health inequalities throughout the lifecourse. As observed in Chapter One, this structure reflects the theoretical orientation of health inequalities research in recent years. It allows us to explore the links between social determinants of health, mediating biological factors and health outcomes and to assess the role of interventions targeting these linkages. It is also broad enough to accommodate more standard approaches to public health (which focus on the role of different risk factors, population groups, policy sectors and health outcomes).

Four critical periods are examined...

As discussed in Chapter Two, early life has become a key focus for both research and policy relating to health inequalities, in part because of the recognition that several risk factors for disease that manifest in later life begin during this earlier stage of the lifecourse. The importance attached to improving health in the early years also reflects the fact that, despite the positive impact of recent changes to the tax and benefit system, rates of child poverty in Britain remain high. Using a poverty line of 60% of median income, an estimated 25% of British children were living in...

As Chapter Four noted, the early years represent a critical period for interventions designed to reduce health inequalities. Inequalities themselves are manifest, exposure to disadvantage is recognised as having lasting effects on health and socio-economic status in later life, and there is strong evidence that childhood health inequalities can be reduced (Mielck et al, 2002). This strategic importance was underlined by theIndependent Inquiry into Inequalities in Health(Acheson, 1998). This identified improvements in early years support for children and families as one of five actions likely to have the greatest impact over time. This emphasis has been maintained. The...

As noted in Chapter Four, much research on the way in which very early life environments affect adult health implies the presence of latency effects, whereby adverse biological or developmental influences at sensitive periods have a lifelong impact on health and well-being, regardless of subsequent living conditions (Hertzman et al, 2001). Because young people are still developing, latency effects may still be at work during childhood and adolescence. For example, evidence suggests that fruit consumption during childhood may have a long-term protective effect on cancer risk in adults (Maynard et al, 2003). Psychological ill health during later life can...

There is a paradox, as Chapter Six has shown, between the relative clinical invisibility of young people and high levels of social concern. Youth, allied with drugs, crime and antisocial behaviour, has arguably dominated domestic home affairs in the UK in the 1990s (Parker et al, 1998), with much of the response and the advocacy coming from the margins of health and welfare rather than mainstream medicine. This chapter, although focusing on the two main sources of inequalities in mortality and morbidity for children and young people, that is accidents and mental health, is also located firmly in the arena...

In the previous two chapters, we focused on pathways and policies relating to health inequalities during childhood and youth. Clear social gradients were highlighted with regard to accidents, injuries and mental health. In other respects, however, evidence of social inequality in current health status is more equivocal. Mortality due to causes other than accidents and injuries shows much less class variation. Similarly, variation in many physical health indicators is neither substantial nor consistent. As noted in Chapter Six, the suggestion that childhood and youth is a period during which a process of equalisation takes place, social variations in health status...

Normal childhood and adolescent development is arguably characterised first by immature and then by inconsistent behaviour, compounded by a sense of invulnerability, experimentation, and a limited concern for future health. This scenario is complicated by two quite different imperatives. On the one hand, young people now face earlier and more intensive exposure to high-risk behaviour, with social and media attitudes encouraging them to look and act older than their years (NSNR, 2000). On the other hand, as Chapter Six has established, there is an increasing delay before the vast majority of adolescents achieve financial and domestic independence. There is thus...

The development of lifecourse approaches to health inequalities has not only addressed the neglect of early life influences in a literature previously dominated by a concentration on adult risk factors for chronic adulthood disease (Davey Smith, 2003). It has also begun to challenge existing research on the relative contribution of such risk factors. For most of the postwar period, research focused on the role of so-called lifestyle factors in determining risk for chronic disease. The individualistic and potentially victim-blaming nature of such research attracted considerable criticism, which may go some way towards explaining why the psychosocial hypothesis (which explicitly considers...

Chapter Ten showed how socio–economic conditions during adulthood continue to exert a powerful impact on health and behaviour. This chapter retains the focus on the key sources of vulnerability, lifestyle, psychosocial health and material living conditions, as we seek to examine the evidence base for what works and its relationship to the policy environment. We note, however, that the boundaries are increasingly indistinct. Housing, for example, has a significant material dimension reflected in housing costs, the generation of wealth, a controlled physical environment and protection from the elements. It also has a significant psychosocial dimension, reflecting self–identity, social...

Due to the overwhelming use of occupational class in health inequalities research, rather less attention has been paid to health differences between sociodemographic than socio–economic groups. In addition to leading to the relative neglect of important characteristics such as ethnicity, the use of occupational status as a basis for classification has had the unfortunate consequence of rendering invisible those who do not participate in paid work by virtue of their older age. Yet, as we discussed in Chapter Three, old age is a period of significant income poverty. Moreover, divisions in wealth are pronounced in older age and the...

There is no consensus as to when old age starts or whether it should be defined by chronological age or frailty. Indeed, as policy initiatives such as Better Government for Older People (BGOP) include all those aged over 50, old age may embrace three generations. There is, however, an undisputed increase in the number of very elderly people and a growth in elderly-only households. These demographic and social trends have combined with factors such as the changing context of informal care and the cost of acute care to focus attention on the health and social care needs of older people,...

It is important that policies designed to address health inequalities are based on reliable evidence. Throughout the course of this book we have examined evidence on the effectiveness of intervention activities targeting a wide range of pathways and processes that give rise to health inequalities across different stages of the lifecourse. To this end, we have drawn on a variety of evidence, supplementing review-level findings with other published literature and grey literature. According to the formal evidence base, remarkably little actually ‘works’. By contrast, the ‘view from the ground’ suggests that local interventions can make a difference to health inequalities....

During the course of this book we have examined a vast array of evidence pertaining to the effectiveness of interventions targeting key public health issues. This includes several hundred non-experimental studies which do not meet the strict criteria for inclusion in systematic reviews but which, nevertheless, throw important light on the complexities of implementing interventions and on the factors that may contribute to successful outcomes. Such studies, however, are not generally considered to be robust enough to provide the basis for definitive policy guidance. Thus, we have also drawn on a formal evidence base. This includes over 125 systematic reviews...