Getting to grips with health inequalities at last?

The World Health Organization’s Commission on Social Determinants of Health published its hard hitting and well received report in mid-2008 with the stark message that “social injustice is killing people on a grand scale.”1 2 The commission’s chair, Michael Marmot, was promptly invited by the UK prime minister and then health secretary for England to consider the implications for health inequalities in England, with a view to informing the government’s post-2010 strategy for tackling them. Fresh thinking and renewed momentum were needed in the face of mounting evidence that the 2010 inequalities targets would not be met.3 The government’s national equality panel has since concluded that inequalities in earnings and incomes are high in the United Kingdom compared with other industrialised countries.4 Economic advantage and disadvantage reinforce themselves across the life cycle.

The Marmot review team submitted its final report to ministers in December, marking the end of a frenetic period of activity involving nine task groups, three working committees, and two interim reports.5 The timing has eerie echoes of the groundbreaking 1980 Black report.6 Although the review chaired by Sir Douglas Black was set in motion by a Labour government, it reported to a Conservative one that was distinctly cool on the subject of health inequalities.

The Marmot report may avoid a similar fate: an election is some months away and all political parties have affirmed a commitment to tackling health inequalities. Nevertheless, as politicians of all hues become increasingly preoccupied with securing electoral advantage, it is questionable whether this important report will receive the careful and considered attention it deserves. There are few votes in health inequalities, and although the report is at pains to point out, as others have, that we are all adversely affected and our lives diminished by the growing health gap,7 this message could easily get lost. More public debate about the sort of society we want to live in might, however, provide a context for greater political courage.

The review advocates two aims: to improve health and wellbeing for all and to reduce health inequalities. To achieve these it wants social justice, health, and sustainability to be at the heart of all policies (box). The report is critical of the poor record of policy success in tackling health inequalities and places an emphasis on delivery systems and leadership. Its attempt to draw lessons from past experience is welcome. Public health experts and academics are adept at producing descriptions of the problem, as are policy makers at developing strategic responses. But the processes of delivering system-wide changes invariably receive less attention.

We believe that three reasons for the lack of progress stand out.8 The first is the phenomenon of “lifestyle drift,” whereby governments start with a commitment to dealing with the wider social determinants of health but end up instigating narrow lifestyle interventions on individual behaviours, even where action at a governmental level may offer the greater chance of success. The response to the Marmot report must avoid this drift at all costs.

The second—a deep seated inability to join up policy and delivery across government, both horizontally at central and local levels and vertically—is evidence of how fossilised our institutional structures have become and how incapable they are of providing effective solutions to the complex problems we face.9 10 The response to Marmot’s recommendations must not mirror the inadequate and simplistic lifestyle oriented solutions to the complex problems of obesity and alcohol misuse.

Merely to do more of what we have always done is not an option. A paradigm shift in thinking is needed. The report singles out the importance of leadership and new approaches to partnership working to deliver change. Conceivably, initiatives like Total Place (a “whole area” approach to providing public services) could herald a new approach to governance and to managing policies and services locally that departs from the tribalism that too often scuppers attempts to work across professional and organisational boundaries.10

The third reason for policy failure lies in the realm of politics. Rhetoric and glossy policy statements aside, is there sufficient genuine and sustainable political will to tackle health inequalities? With the economic outlook bleak and an election looming, the temptation will be for politicians to say that we can’t afford to deal with health inequalities just yet. The imperative is to show that we can’t afford not to. This will be the Marmot report’s sternest test.

The policy changes needed for Marmot’s recommendations to succeed can occur only if these three obstacles to progress are confronted. A focus on individual lifestyle must not be allowed to obscure the need for appropriate government action. This action should go hand in hand with a more radical shift in implementation that will require new forms of adaptive leadership11 and looser partnership structures that allow for flexible solutions tailored to local contexts,12 and which provide genuine space for community empowerment. Underpinning these must be a real political commitment at all levels, because a fairer society will benefit all. The Marmot report, aware that its timing is less than auspicious, says inaction is not affordable. Both this government and its successor should heed the warning, for the journey will be both long and arduous.