4 Communities: tackling the wider causes of ill-health

4.1 Individual behaviour is often vitally important in improving, safeguarding or damaging health. But poor health can also spring from a complex interaction between the genetic make-up and behaviour of individuals and social, economic and environmental factors in the community.

'Health inequality runs throughout life'

4.2 Health is also profoundly unequal. Health inequality runs throughout life, from before birth through into old age. It exists between social classes, different areas of the country, between men and women, and between people from different ethnic backgrounds. But the story of health inequality is clear: the poorer you are, the more likely you are to be ill and to die younger. That is true for almost every health problem.

4.3 Over recent years it is the health and well-being of people living in the most run-down communities which have suffered most. Poverty, low wages and occupational stress, unemployment, poor housing, environmental pollution, poor education, limited access to transport and shops, crime and disorder, and a lack of recreational facilities all have had an impact on people's health.

'run-down communities have suffered most'

4.4 The impact that could be made by an attack on health inequality is clear. For example, if the death rates of all men of working age were the same as those in professional and managerial jobs, about 17,000 deaths would be avoided each year of which about 75 per cent would be in our four priority areas: cancer, coronary heart disease and stroke, accidents and suicide.

Fig 4.1 Death and disadvantage: excess death rates amongst men in non-professional classes

4.5 The Acheson Inquiry, which published its Report in November 1998, confirmed that for many aspects of health, inequality has generally worsened in the last few decades, especially in the 1980s and early 1990s.

'The Acheson Inquiry confirmed inequality has generally
worsened in the last few decades'

4.6 The Government is publishing an action plan on tackling health inequality at the same time as this White Paper. The plan addresses the social, economic and environmental factors and the part they play in poor health.

The scale of the challenge

4.7 Successful health education campaigns in the past have tended
to widen inequality, because the better off took more notice and changed their behaviour faster than others did. We are determined to make sure that future campaigns are designed to have most effect on those most need in need (see paragraph 11.6).

Fig 4.2 The widening mortality gap between social classes

4.8 During the 1980s and 1990s the gap between rich and poor widened and the health gap grew wider. We are determined
to close it in the new millennium. Our policies will have the cumulative effect of setting us on a new course of regenerating health on a massive scale with most effort targeted on those most in need.

'we refuse to accept such inequality as inevitable'

Evening up opportunity

4.9 While the roots of health inequality run deep, we refuse to accept such inequality as inevitable. Moreover, we fully accept the responsibility of Government to address such deep-seated problems. That is why we are committed to a wide-ranging programme of action, right across Government, to tackle them.

'we fully accept the responsibility of Government to address
such deep-seated problems'

4.10 Because tackling social exclusion is one of the Government's highest priorities the Prime Minister established a Social Exclusion Unit at the heart of Whitehall. Health is an important dimension of social exclusion, which involves not only social but also economic and psychological isolation. Although people may know what affects their health, they can find it difficult to act on what they know, setting up a downward spiral of deprivation and poor health.

4.11 In some areas there is persistent inequality between men and women. The Women's Unit which we have established in the Cabinet Office dovetails with the work of the Social Exclusion Unit. Current work on tackling violence against women, parity in old age, balancing home and work, teenage girls and risk behaviour, all have relevance for improving health and cutting inequality.

'making it easier for people to escape from the benefits
trap into work'

4.12 Action to tackle health inequality needs to be targeted in different ways in different places. An inner city area will need different approaches from a remote rural area. We shall publish an Urban White Paper and a Rural White Paper which will, amongst other things, address the health needs of local communities and social exclusion.

Security and health

4.13 The strong association between low income and ill-health is clear. For many people the best route out of poverty is through employment. We are making it easier for people to escape from the benefits trap into work, for example through our tax and benefit reforms, such as the Working Families Tax Credit and the Childcare Tax Credit and through introducing the first ever national minimum wage in this country.

'introducing the first ever national minimum wage in this country'

4.14 For those who cannot work, a secure income is important
to safeguard their health. We are determined to provide them with the security they need. That is why the Department of Social Security is working to ensure that people who are entitled to benefits actually claim them. Mothers with young children may find it very difficult to combine their family responsibilities with adequately paid employment. We are therefore introducing changes that will make work pay and good quality child care affordable. And we are targeting support towards all families with young children by increasing child benefit by the highest ever amount, and increasing the allowances for children in the income-related benefits.

4.15 Older people too and some disabled people are unlikely to be in full-time work - we have introduced a minimum income guarantee for pensioners and a disability income guarantee for the most severely disabled people. We have allocated £500 million to make winter fuel payments part of all pensioners' income. We have also given pensioners an entitlement to free NHS eye-tests. We are committed to a national minimum standard for local authority concessionary fare schemes of half-fare on buses. The Green Paper Partnership in Pensions, published last December, described our proposals for a New Insurance Contract for pensions, with a minimum income guarantee for pensioners.

Education and health

4.16 Education is vital to health. People with low levels of educational achievement are more likely to have poor health as adults. So by improving education for all we will tackle one of the main causes of inequality in health. Education can build self-esteem and can equip children and young people with the skills to adopt a healthier lifestyle. Education can also contribute to general improvement in healthby enhancing people's ability to secure opportunities for work.

'by improving education we will tackle one of the main causes
of inequality in health'

4.17 We set out in our White Paper Excellence in schools our commitment to early years education and to helping all schools to become healthy schools. A healthy school is one where good health and social behaviour underpin effective learning and academic achievement, which in turn promotes long-term health gain. The Healthy Schools programme has set up pilot partnerships between education and health authorities to provide the context and support for a healthy environment for school communities. Building on the lessons from the pilots we expect to roll out the scheme nationally from the autumn. The national programme, supported in 1999-2000 with £4 million jointly from the Department of Health and the Department for Education and Employment, will provide the opportunity for all schools to participate.

'the Cooking for kids programme is a long term strategy for
cutting heart disease and cancer'

4.18 The programme has also set up a wide range of supporting projects to assist schools in meeting the standards expected by
a national scheme. These include:

• Wired for Health, www.wiredforhealth.gov.uk a website designed specifically for schools with information
  to help young people make informed decisions about their health and assist teachers in dealing with health issues in schools

• Cooking for kids, a programme that supports the teaching of basic cooking and food preparation skills, facts about nutrition and food hygiene to children in the school holidays. By the end of the summer we expect to have involved over 15,000 children across England. The Cooking for kids programme is part of a long-term strategy for cutting coronary heart disease and cancer by giving children an understanding of what makes a diet healthy. It provides opportunities for expanding the provision of school breakfast clubs and improving the nutritional value of school meals

4.19 We recognise the vital contribution that physical activity makes as one of the foundation subjects of the national curriculum. Good physical education and school sports provision are essential to the foundation of lifelong positive attitudes towards health and fitness. We support the work that Sport England does to put in place a sound framework for physical education and sport through its Active Schools programme. Ensuring a step change in the provision of school sport will be a major message of the Government's Sports Strategy paper.

Employment and health

4.20 People in work enjoy better physical and mental health than those without work. Unemployment increases the risk of illness and premature death. For example: a middle-aged man who loses his job is twice as likely to die in the next five years as a man who remains employed.

4.21 Under the New Deal, young people, the long-term unemployed, lone parents and disabled people are being offered the opportunity to move off benefit and into work. We are investing £3.9 billion in the period to 2001-2 in Welfare to Work programmes which will help equip people with the education and skills they need to get jobs and keep them.

'the opportunity to move off benefit and into work'

4.22 But people can also be exposed in the workplace to health risks. Minimum standards for health and safety at work are laid down in legislation. But levels of work-related ill-health are still high. In 1995 in Great Britain two million people suffered from a work-related illness, and around 20 million working days were lost through work-related ill-health - though this is partly due to wider economic and industrial changes which affect patterns of work-related ill-health.

4.23 Last summer the Health and Safety Executive launched a discussion document to develop a new occupational health strategy. In addition, the Deputy Prime Minister has announced a strategic appraisal of health and safety, to inject a new impetus into the health and safety agenda 25 years after the Health and Safety at Work etc Act 1974. A consultation document will be launched in July and the outcome of the appraisal will be announced in November.

'Effective action will improve competitiveness by reducing
sickness absence'

4.24 Effective action by employers and employees will improve competitiveness by reducing sickness absence rates; it will also improve the health of the local communities which provide the workforce.

4.25 The workplace provides opportunities both to improve the health of the workforce and to address health inequality. The health of people at work is a core issue for management. A healthy workforce is a pre-condition for competitiveness and business success.

4.26 Some work conditions can have a profound impact on health. For example, the evidence shows that people in jobs which place high demands on them over which they have no control are at much higher risk of coronary heart disease - one of our four priority areas. A healthy workplace will bring employers and employees improved productivity, lower rates of sickness absence, fewer accidents and less illness.

4.27 In March 1999 the Ministers for Public Health and for Health and Safety launched the Healthy Workplace Initiative, based on the message that Improving Health is Everybody's Business. The initiative will promote healthy workplaces by:

• developing examples of good practice for handling key workplace health issues

• making available relevant and up-to-date information, for example to help alleviate back pain

• encouraging better access to services and helping to provide

• a bridge between prevention, treatment and rehabilitation

• helping to promote compliance with relevant workplace legislation

Housing and health

4.28 Most people spend more time in their own homes than anywhere else. So good quality housing inevitably has an important impact on health. Homes should be safe, warm, dry and well-ventilated with amenities which meet minimum standards of comfort, such as indoor toilets. There are still about 1.5 million dwellings which fall short of the current housing fitness standard laid down in primary legislation.

'good quality housing inevitably has an important impact
on health'

4.29 The most important risks to health from poor housing come from cold and damp, which cause a number of illnesses including respiratory diseases. Very old people, small children and the chronically sick are most vulnerable to this increased risk. Typically, in any one winter there will be 2.5 million homes in England cold enough to cause ill-health, and two million of those will be occupied by people in these vulnerable groups. From December to March, year on year, there are between 20,000 and 50,000 excess deaths compared to the rest of the year. Cold housing is one of the factors responsible. Keep Warm Keep Well for older people is one of the ways we shall tackle this issue (see paragraph 3.46).

Fig 4.3 Asthmatics are two to three times more likely than the general population to live in damp properties

4.30 We are reviewing the current fitness standard and have proposed replacing it with a new rating system which is currently being piloted. This would include all the important health and safety risks in the home including poor energy efficiency. The new system would provide a more effective way of identifying those dwellings which present the worst risks and taking action to remedy them. A National Licensing System for houses in multiple occupation will help tackle the worst housing conditions.

'fuel poverty policy to help vulnerable people'

4.31 Many people live in homes which do not use energy efficiently. This pushes up the cost of household fuel bills. Those people are likely to be the most vulnerable members of society - those with low incomes, families with young children and older people. We have reviewed our entire fuel poverty policy to see how we can bring extra help to these vulnerable people. We are now consulting on our proposals.

Homelessness

4.32 Homelessness is one of the worst effects of social exclusion and can be a significant cause of ill-health. We have pledged to place a new duty on local authorities to protect those who are homeless through no fault of their own and who are in priority need. We have already strengthened the safety net for homeless people and ensured that households which are accepted as unintentionally homeless and in priority need are given reasonable preference in the allocation of permanent social housing. We are also considering what more help they may need.

4.33 Our aim is to reduce the number of people sleeping rough by two thirds by 2002. Following the recommendations of the Social Exclusion Unit in July 1998, we announced that a new London Rough Sleepers Unit with a budget of £145 million over three years would co-ordinate Government initiatives in the capital. The Unit has started to tackle the full range of housing, health care, education and training needs of people sleeping rough in London. The Government has also announced a new £34 million Homelessness Action Programme to tackle rough sleeping and single homelessness outside London. This programme helps to support local strategies addressing rough sleeping and single homelessness.

'to reduce the number of people sleeping rough by two
thirds by 2002'

Healthy neighbourhoods

4.34 People relate closely to their neighbourhoods, and are likely to be healthier when they live in neighbourhoods where there is a sense of pride and belonging. Evidence, particularly from the World Health Organisation, shows how social cohesion and strong social networks benefit health.

4.35 The Neighbourhood Renewal Policy Action Team set up by the Social Exclusion Unit and headed by the Department for Culture, Media and Sport has found that participation in arts and sport can promote social cohesion by building strong social networks. Health action zones, healthy living centres and family doctor practices all offer the potential to promote active lifestyles to benefit local communities.

4.36 The close link between regeneration and health is reflected in our New Deal for Communities initiative - a key part of our work to turn around our most deprived neighbourhoods. Under it we have set up a new fund, worth £800 million over three years, to help improve the poorest neighbourhoods and encourage local people and agencies - public, private and voluntary - to work together to overcome the problems of multiple deprivation and to make a lasting improvement to their neighbourhoods.

'£800 million over three years, to help improve the poorest
neighbourhoods'

4.37 At the same time we are targeting a reshaped Single Regeneration Budget (SRB) - worth £2.4 billion over three years - on the most deprived local authority areas and creating 50 large comprehensive schemes - at least one in each of those areas by the end of this Parliament. SRB schemes can contribute to improvements in health by developing partnerships with local health bodies to counter factors which make neighbourhoods unhealthy and to promote healthier lifestyles and improve access to community-based health facilities.

'a reshaped Single Regeneration Budget worth £2.4 billion
over three years'

4.38 Health For All and Local Agenda 21 are both long-standing local authority commitments which bring together improvements in health with improving the environment. The World Health Organisation's Healthy Cities Programme is one strand of Health For All, promoting an integrated approach to improving people's physical, social, mental and environmental well-being through putting health on the agenda for the decision-makers in cities and building a strong lobby for public health at local level.

4.39 Under Local Agenda 21, a comprehensive action plan at the local level to promote sustainable development for the 21st Century in urban and rural areas alike, many communities have focused on action which also delivers improvements to health. Projects such as establishing allotments and community gardens engage inner city communities in improving the local environment and producing fresh fruit and vegetables, leading to employment, improved diet and a stronger sense of community.

4.40 Underpinning all these initiatives is our planning policy which has at its heart the need for sustainable communities. Health is an important aspect of sustainability, as we recognised in our recently published good practice statement Sustainable Development: Towards Better Practice. We shall continue to use the planning system to support local shopping facilities which are accessible to non-car users, to encourage healthier transport options such as walking and cycling, to promote more sustainable patterns of development for housing, and to prevent the loss of playing fields which form an essential resource for promoting the enjoyment of physical recreation.

Environment and health

4.41 People value, enjoy and draw benefit from a good and healthy environment. The link between health and the environment is long-established. We now have a better understanding of the diverse ways in which the environment can affect health - the factors which cause pollution, for example, and the way in which they affect health.

Environment and health 100,000 houses in the UK have high levels of radon gas - radon exposure is associated with an increased risk of certain cancers

4.42 We are addressing these issues:

4.43 Poor air quality is a serious health hazard. In 1998 the Committee on the Medical Effects of Air Pollutants published a telling report on the problem - Quantification of the Effects of Air Pollution on Health in the United Kingdom. Air pollution is thought to be responsible for shortening as many as 24,000 lives each year. Particulates in the air are likely to be responsible for bringing forward the deaths of 8,100 people in the UK every year, and to contribute to an additional 10,500 hospital admissions for respiratory problems. Our tough health-based targets for improving air quality will lead to substantial improvements over the next few years, including a reduction in the amount of ill-health due to poor air quality.

'health-based targets for improving air quality'

4.44 The UK Government hosted the largest ever Ministerial conference on environment and health in June 1999, leading the way in Europe on joined-up approaches to the wider determinants of health. Ministers from over 50 countries agreed action in partnership on many important factors impacting on health - water, transport, climate change, the workplace - looking forward to healthier nations in the 21st Century.

Health Impact Assessment

4.45 We need to ensure that in all areas of Government policy-making the actions that flow from our policies will contribute to our goals of improving the health of the population and reducing inequality. So we have decided that major new Government policies should be assessed for their impact on health.

'major new Government policies should be assessed for their
impact on health'

4.46 This assessment process is important because it acknowledges for the first time the relationship between health and the impact of Government policy generally. We intend to make health impact assessment a part of the routine practice of policy-making in Government. We have already commissioned the first assessments of some of our major national policies, on fuel poverty and the New Deal for 18-24 year-olds, and we shall continue to apply the approach in other areas, right across Government.

4.47 Local decision-makers must think about the effect which their policies may have on health and in particular how they can reduce health inequality. In most cases this will require a change in the way that health authorities, local authorities and other local agencies see their role. They will in future need to act much more as health champions at local level and ensure that health is on the agenda of all local organisations and agencies outside the health field. An important part of this role will be to encourage all local agencies to make local health impact assessments when planning investment in, for example, amenities, buildings or local communities and in the location of services.

We welcome your comments on this site. Prepared 5 July 1999