Reducing Inequalities in Health

Introduction: assessing the evidence
We have sought to ensure that our recommendations are based on scientific and expert evidence. To this end, we have consulted with a wide range of experts and incorporated a process of peer review. In summary, we commissioned a series of input papers from experts broadly to match the sections of the report. Most of these experts consulted widely amongst other researchers in their field. For each of these commissioned papers, we obtained an independent scientific commentary. We also sought and received a considerable volume of material from institutions and individuals with expertise or experience relevant to inequalities in health, including scientific reviews and papers. A separate Evaluation Group was convened to consider the commissioned papers with associated commentaries and asked to report on the quality of the evidence on which the recommendations in the papers were based, and to identify gaps64. A more detailed description of the process is given in annex B.

All this material was considered and discussed within the Scientific Advisory Group. The material reflected a wealth of descriptive data documenting inequalities in health and a growing quantity of research exploring mechanisms. However, controlled intervention studies are rare. Indeed, the more a potential intervention relates to the wider determinants of inequalities in health (ie "upstream" policies), the less the possibility of using the methodology of a controlled trial to evaluate it. We have, therefore evaluated many different types of evidence in forming our judgement. The following sections incorporate our assessment of the full spectrum of evidence which we reviewed.

Cross-Government Issues
If future inequalities in health are to be reduced, it will be essential to carry out a wide range of policies to achieve both a general improvement in health and a greater impact on the less well off. By this we mean those who in terms of socioeconomic status, gender or ethnicity are less well off than average in terms of health or its principal determinants - such as income, education, employment or the material environment.

The impact of policies designed to improve health may have different consequences for different groups of people which are not always appreciated. Some policies will both improve health and reduce health inequalities. The introduction of the NHS benefited the health of all sections of the population, particularly women and children, many of whom were excluded from previous arrangements under the National Insurance Act.

A well intended policy which improves average health may have no effect on inequalities. It may even widen them by having a greater impact on the better off. Classic examples include policies aimed at preventing illness, if they resulted in uptake favouring the better off. This has happened in some initiatives concerned with immunisation and cervical screening, as well as in some campaigns to discourage smoking or to promote breastfeeding. More recently, the Government's welcome decision to provide a pre-school place for every child aged four in the country is likely to benefit health on average but could have the unintended effect of increasing inequalities. This would happen if the children of the better off made more effective use of the service.

These examples highlight the need for extra attention to the needs of the less well off. This could be accommodated both by policies directed at the least well off and by an approach which would require the need for inequalities to be addressed wherever universal services are provided, such as publicly funded education and the National Health Service, and where other policies are likely to have an impact on health.

A broader approach of this kind which explicitly addresses inequalities could provide a new direction for public policy. It is our view that, in general, reductions in inequalities are most likely to be achieved if policies are formulated with the reduction of inequalities in mind.

1. We RECOMMEND that as part of health impact assessment, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce such inequalities.

This proposal for a systematic impact assessment of policy on health inequalities is a significant extension to the steps already taken by Government to apply impact assessments to its policies1, and to ensure better coordination across Whitehall.

We suggest that this proposal needs to be supported by a small and effective unit with a pan-Government view. Such a lead by Government would allow action on inequalities to be both reviewed and promoted. It would also serve to further encourage the steps being taken to strengthen coordination at both central and local level.

1.1 We recommend establishing mechanisms to monitor inequalities in health and to evaluate the effectiveness of measures taken to reduce them.

The effects of future policies will need to be monitored at regular intervals. For this purpose, the Government will require authoritative statistics on inequalities in health and the factors influencing them at national and local level. These will also be needed in order to set targets for reduction of health inequalities. A number of concerns about the presently available data have been raised with us. These include the scope for monitoring inequalities among older people, when many data sources have an effective cut-off point of age 64. There are continuing inconsistencies in the treatment of males and females in the census and at death registration, where married women are still mainly classified by the social class of their husband. There is also a need for greater consistency between data from the census, from vital registration and from other sources.

1.2 We recommend a review of data needs to improve the capacity to monitor inequalities in health and their determinants at a national and local level.

We have emphasised the priority we will be giving to parents and children in the report as the best way of reducing future inequalities in physical and mental health. This issue is relevant across Government.

2. We RECOMMEND a high priority is given to policies aimed at improving health and reducing health inequalities in women of childbearing age, expectant mothers and young children.

Areas for Future Policy Development

1. Poverty, Income, Tax and Benefits

Poverty and income

Inequality
Inequalities in health are of long standing and their determinants are deeply ingrained in our social structure. Since 1980, although health and expectation of life have generally improved, the social gradients of many indicators of health have deteriorated or at best remained unchanged. Although this period was also marked by substantial economic growth, income differentials widened to a degree not seen since the Second World War. It also saw the reversal in the trend to greater equality seen in the 1960s and 1970s. Average incomes grew in real terms by about 40 per cent between 1979 and 1994/5, but this growth was far greater (60-68 per cent) amongst the richest tenth of the population. For the poorest tenth average income increased by only 10 per cent (before housing costs) or fell by 8 per cent (after them). There has been some improvement in the relative position of the poorest groups in the period since 1992 but income inequality is still pronounced and is worse than in many other developed countries65.

The differences in incomes between those on means-tested benefits and those with other sources of income are a major determinant of income inequality in the United Kingdom. Among the poorest fifth of the population, the majority have incomes set by the level of means-tested benefit65. People on low income, defined as below half average income, are more likely to be unemployed, lone parents and their children, people with disabilities or pensioners and to live in social housing. Some minority ethnic groups, especially Pakistanis and Bangladeshis, are over-represented in the poorest fifth of the income distribution65-69.

A similar picture emerges if poverty is defined as the receipt of Income Support. Almost a quarter of all households include at least one person receiving Income Support70. Measured over a two year period, this figure rises to more than a third. The number of people receiving Income Support has risen from just over 4 million in 1979 to 9.6 million in 199671. Comparisons over time are difficult but recent work has shown that the proportion of the population with below half average income has more than doubled since 1979, to reach 18 per cent in the mid 1990s72.

Many studies and analyses have demonstrated the association of increasingly poor health with increasing material disadvantage. For instance, all cause mortality is correlated with Townsend deprivation score, an index which combines indicators of unemployment, lack of car, not being an owner occupier and overcrowding. The highest mortality rates for both men and women are found among those who live in areas with the highest scores (most deprived), and the lowest in those from areas which are least deprived73. People living in households with incomes of £350 or more per week have significantly lower rates of self-reported long standing illness than those living in households with an income of £200 per week or less74. However, available evidence is insufficient to confirm or deny a causal relationship between changes in income distribution and the parallel deterioration in inequalities in some areas of ill health. Nevertheless, we take the view that these changes are likely to be related. In addition to being responsible for part of the burden of morbidity and mortality, they probably contribute to the persistence of the steep, unfavourable socioeconomic gradients in smoking and in the consumption of important nutrients such as antioxidants. Perhaps even more important is the damage persistent family and childhood poverty does to the health of future generations.

We welcome the Government's declared intention to redress income inequalities through the establishment of a national minimum wage, "Welfare to Work" and other measures. This approach should be accompanied by efforts to redistribute resources, in cash or kind, to those who, for reasons such as age or disability, are unable to work, and to those families for whom work is not available or appropriate. We consider that without a shift of resources to the less well off, both in and out of work, little will be accomplished in terms of a reduction of health inequalities by interventions addressing particular "downstream" influences.

Tax and Benefits

A fairer tax system will help the less well-off who are in work. It can boost the incomes of those in low paid work, neutralise the poverty trap for those able to work and reduce inequalities. Recent changes, such as "Welfare to Work" and the announcement of the Working Families Tax Credit Scheme in the 1998 Budget, explicitly recognise the link between tax and benefits for working families. It is too early to assess the effects of these changes and they will need to be kept under review. It is our view that more may need to be done. Over the last 20 years a greater proportion of total taxation has been raised by indirect taxes75, notably through VAT but also through excise duties. We note the Government's pledge not to extend VAT to food, children's clothes and public transport fares, and the action it has taken to reduce VAT on domestic fuels in a direct effort to help poorer and older people. Shifting the tax burden from regressive to more progressive forms of taxation and fiscal policies which take account of the combined impact of direct and indirect taxation on the living standards of lower income groups, would help mitigate the effects of income inequalities.

For the least well-off members of society, however, it is the benefit system which is the principal determinant of living standards. A comprehensive review of the social security system and its implications for health are beyond the capacity and competence of the Inquiry. Welfare reform is, however, on the Government's agenda. We believe it is important that, over time, benefit and pensions levels are set at a level sufficient to pay for items and services necessary for health and for participation in society.

We have decided to focus on two groups where we believe the current system fosters major inequalities in health and which will not reap the full benefits of the Government's recent, work-related reforms. These groups are families with children and pensioners.

Evidence
Poverty falls disproportionately on children. In the mid 1990s, around one in four of the total population in Britain were living in poverty (below 50% of average income after housing costs). Among children, the proportion was one in three76. In 1996, 2.2 million children were in a family receiving Income Support77.

A child, and additional children, has a much greater impact on the standard of living of poorer than better-off households78. Yet current levels of benefits are not generous, either relative to average incomes or to levels found in much of continental Europe79. Income Support falls significantly short of the level that independent experts determine to be the modern minimum. In 1992/3, the income of a single pensioner, owner occupier on Income Support fell £8 per week short of the standard; a couple with two children needed £34 more benefit to reach the standard80,81. Depending on age, Income Support rates meet between 67 per cent and 90 per cent of minimum needs of children, as assessed by a representative cross-section of parents82. Another study found that Income Support levels are insufficient to meet the costs of an adequate diet for expectant mothers, particularly single women under the age of 2583. Studies of the cost of meeting the basic needs of children of different ages suggest not only that the income provided by Income Support is insufficient but that the personal allowances for children understate the costs of younger children (especially those under 2 years) relative to older children65,84. Independent and expert assessment of basic needs also indicates that the personal allowances paid to one- and two-parent families underestimate the relative cost of providing a basic standard of living for one-parent families78,84,85. It is estimated that a lone parent with two children would need 93% of the amount required by a couple with two children to achieve the same "modest but adequate" standard of living85. The 1998 Budget with above inflation increases in the benefit rates for younger children, childcare tax credit for working parents and the working families tax credit will contribute to the narrowing of these discrepancies. Substantial improvement will require sustained action but this is an important start which goes some way to narrowing these discrepancies but will not eliminate them.

The switch to link benefits to prices rather than earnings in the early 1980s has meant a relative deterioration in the position of groups who rely on benefits, including pensioners (figure 13)65. The poorest pensioners are those wholly dependent on the State Retirement pension and although this is designed to be supplemented by Income Support, some one million - or around one in four of state retirement pensioners - do not claim support to which they are entitled86,87. A number of factors may operate, including lack of knowledge of entitlement, a perception of being stigmatised by the receipt of benefit and physical or other difficulties in the processes of claiming. Possible ways of overcoming some of these problems are the establishment of new organisations or agencies: a pensioner's agency as a way of achieving "one-stop" provision of welfare88: a citizen's bank88: or a welfare "counsellor" in primary care centres in disadvantaged areas89,90. A further suggestion to the Inquiry has been that an Income Support "top-up" could be paid automatically to bring the poorest pensioners up to Income Support levels.

There is a lack of experimental evidence that increasing financial resources results in measurable health gain. A rare exception is a randomised controlled trial carried out in Gary, Indiana, USA between 1970 and 1974. The intervention group received an expanded income support plan which guaranteed a minimum income to a group of mothers with low income. Mothers at high risk of adverse pregnancy outcome had heavier babies if they had received the income support plan91. However a review, which is being carried out under the auspices of the Cochrane Collaboration, has not been able to identify other evaluations of financial support interventions which include health outcomes, meeting review quality criteria64.

Thus the bulk of the empirical evidence comes from research demonstrating that people living on low incomes, including those whose income consists entirely of state benefits, have insufficient money to buy items and services necessary for good health. Studies of the budgeting arrangements of poor families show that the money for food is often used as the reserve to iron out fluctuations in income and meet emergencies92. Mothers often shop alone to curtail expenditure and shop frequently to prevent food being available at home and therefore at risk of being consumed before it is essential. Spending is much reduced in the second week of the benefit cycle. Families can and do go short of food during this time because of shortage of money and, more often than not, it is the mother who goes without93-95. Some mothers have nutritionally deficient diets, although they are usually successful in protecting the diets of their children94. Older people are particularly at risk of "fuel poverty" and may under-heat their homes because they cannot afford to buy fuel96,97. Poverty may also act as a barrier for older people to services and care and to an adequate diet.

Benefit
Policies which increase the income of the poorest are likely to improve their living standards, such as nutrition and heating and so lead to improvements in health. This can be done by improving social security benefits, specifically for families with young children and pensioners, by increasing employment opportunities and through changes in the tax system. We have already noted that what is affordable in this area is a matter for the Government rather than the Inquiry.

At a population level, improvements in income and living standards are clearly associated with improvements in health and life expectancy98. As the effects of such interventions on individual health have not been tested, any possible harmful side effects are unknown, if unlikely.

3. We RECOMMEND policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits. Specifically:

3.1 we recommend further reductions in poverty in women of childbearing age, expectant mothers, young children and older people should be made by increasing benefits in cash or in kind to them.

3.2 We recommend uprating of benefits and pensions according to principles which protect and, where possible, improve the standard of living of those who depend on them, and which narrow the gap between their standard of living and average living standards.

3.3 We recommend measures to increase the uptake of benefits in entitled groups.

We recommend further steps to increase employment opportunities (recommendation 8.1).