Do you want a better NHS or more equal health outcomes for all?

Jonathan Wistow, lead author of Studying health inequalities which published this week, explains why a better NHS is not necessarily the answer to ensuring greater health equality.

Wistow4Few things are as important to the quality of life as the number of years healthy life expectancy and overall life expectancy. 

So why, nearly 70 years after the creation of the NHS, do we have wide variations in health outcomes that are related to peoples’ different and unequal positions in society?  We might expect a universal free at the point of delivery health service to narrow these inequalities.  However, this has not been the case.

Social problem

To address this issue, it is necessary to view health inequalities as a ‘social problem’ – a problem that is created by, and exists within, society.  As such health inequalities provide a useful and significant insight into the dynamics of contemporary societies.

They reflect (amongst other things) the distribution of wealth; the way that we live our lives; the way that services are organised; the quality of, and access to, different services and amenities; the history of places; where people want to live; where people actually live; what people do for work; and the opportunities and options people have throughout their different life stages.

“health is too often conceived of as an individual and medical issue in both the way it is resourced and understood”

However, health is too often conceived of as an individual and medical issue in both the way it is resourced and understood. This is significant not only in terms of how public resources are prioritised (particularly during periods of austerity) between NHS, public health, local government and community and voluntary sectors but also in terms of how we view rights to services and/or outcomes.

Following a general election when resourcing of the NHS was a major issue and priority for all of the main political parties it is reasonable to ask whether we want a better NHS or more equal health outcomes for all?  These are not necessarily mutually reinforcing goals.  The former is about service delivery and the allocation of public funds and the latter is about redistribution as well.

A key issue to consider here is the nature of the social contract and how the balance between individual and social rights is prioritised. In the UK over the past 30-40 years a more or less free market based capitalism centred on individual rights has been pursued and we have witnessed a substantial increase in socio-economic inequalities in this period.

This shapes how equality is viewed and the extent to which there is a challenge to divisions of power, wealth and security in society. In turn this has implications for both the existence of inequalities in health and policy solutions to these.

“we are more concerned with individual rights to services than with collective rights to more equal outcomes”

Consequently, despite the existence of the NHS we are more concerned (in policy at least) with individual rights to services than with collective rights to more equal outcomes. Such a move to more equal health outcomes would require a much more fundamental redistribution of health across society and a return to the European tradition of pursuing equality of condition.

There is a further methodological issue that is important for framing how we understand and, as a result, respond to health inequalities. At an individual level potential causes of health inequalities relate to a complex combination of lifestyle behaviours which influence the socio-economic distribution of health risks associated with, for example, smoking, diet, exercise, bodyweight, and exposure to sunlight.


It is very difficult to isolate these behaviours and attribute causation to them as individual variables. Indeed we can question whether this is a desirable strategy given that in practice people do not live their lives in neat and separate component parts: diet, frequency of exercise, social and work activities, alcohol and nicotine consumption, are all parts of the complex whole that make up individuals’ lifestyles.

But this is still not the whole picture. Lifestyle, in turn, relates to (but is not wholly determined by) the contexts in which people live their lives. Different people react to these different contexts differently.

When we talk about contexts here we take a broader approach, including family, workplace, neighbourhood settings, towns, cities and regions – all important contextual characteristics within which people lead their lives.  It follows that we should take a research approach that concentrates on the complex interactions between people and settings.

To develop more equitable health outcomes in society our understanding of health needs to be based on the kinds of policy, ideological and methodological issues identified above.  Without such a broad consideration achieving fairer health for all seems particularly challenging.  However, there is scope to consider health as a key focus for redistribution and one that may help to move equality back up the political agenda.

Jonathan Wistow is a researcher and teaching fellow, in School of Applied Social Sciences, Durham University.  His interests include health inequalities, governance and local government.


Studying health inequalities [FC] 4webStudying health inequalities published on 30th June 2015 and you can order your copy from our website here (RRP £24.99).

Don’t forget that until Monday 6th July Policy Press newsletter subscribers get a 40% discount when ordering any of our books through our website. If you’re not a subscriber yet why not sign up here today and join our Policy Press community?

The views and opinions expressed on this blog site are solely those of the original blogpost authors and other contributors. These views and opinions do not necessarily represent those of the Policy Press and/or any/all contributors to this site.

Children First, Offenders Second

In today’s guest post Kevin Haines and Stephen Case, whose book Positive Youth Justice: Children First, Offenders Second publishes today, caution against overlooking the “Child” in childhood crime prevention.

Steve pic

Stephen Case Swansea University

Kevin Haines Swansea University

Children have a special place in society and deserve special treatment due to their lack of maturity, their relative powerlessness in decision-making processes and the need for adults to provide them with support and protection.

However, when children enter the Youth Justice System (YJS) of England and Wales, it seems that their treatment becomes ‘special’ in the sense of discriminatory, negative, controlling and punitive.

Children who commit crime, it seems, are held responsible for their perceived psychological and social ‘failings’ and ‘deficits’, which are seen to contribute to offending behaviour and to the failure of any formal interventions aiming to prevent future offending.

This unpalatable, grossly unfair situation has to change. Consequently, we have formulated a principled and progressive model of ‘positive youth justice’ that is fit for purpose and fit for our time.

Children First

Children First, Offenders Second (CFOS) is a positive approach to youth justice that is built on a set of policy and practice principles, the key to which is to treat children in child-friendly and child-appropriate ways.

Simply put, when children enter the YJS, we should treat them as ‘children first’, not ‘offenders first’ and treat their offending behaviour as a normal part of growing up.

“CFOS is a reaction to controlling, punitive and harmful interventions”

The philosophy of children first will help youth justice professionals to understand why they come into work every day and provide them with a touchstone against which they can measure their daily practice.

CFOS enables staff to understand what they do, why they do it in the way they do it and how they can reflect on the appropriateness and effectiveness of their work. It is a guiding philosophy for practice that gives clear objectives for practice and gives practitioners a sense of purpose to frame and animate their knowledge and skills.

Without this coherent and explicit philosophy, policies and practices are information and understanding without knowledge; skills are abilities and techniques without foundation or application.

CFOS is simultaneously reactionary and progressive. It is a reaction against the ways in which youth justice policies and practices subject children to (possibly well-meaning) interventions that are ultimately controlling, punitive and harmful. It is progressive in its philosophical, principled position and in its policy-practice focus.

We believe that for youth justice policies to be implemented effectively in practice, they must have clear, overarching objectives and be targeted on three key practice areas along a continuum of youth justice:

The Three Principles


Negative outcomes can be stopped.

Prevention (Positive Promotion): We advocate for the promotion of positive behaviours, outcomes, services and opportunities for all children, within and outside of the YJS.

The approach can be animated by adult service providers designing and delivering services in partnership with children; services that prioritise children’s consultation, participation and engagement in all decisions that affect them.

We evidenced this effectiveness in our national evaluation of the Welsh youth inclusion strategy ‘Extending Entitlement’ (Case et al 2005) in terms of improved positive outcomes and reduced negative outcomes (for children in the YJS) as well as improved perceptions of access to entitlements and ability to participate in services (for all children).


More constructive routes can often be found.

Diversion: We support a progressive diversion approach based on diverting children out of the formal YJS and into positive, promotional interventions.

The effectiveness of progressive diversion has been evidenced by the Bureau model (now rolled out across Wales), which prioritises systems management (child-focused decision-making at all stages of the youth justice process) and partnership between practitioners (e.g. police, youth justice staff, teachers), children and families during assessment (prolonged, holistic assessment process consulting with all relevant parties), decision-making/sentencing and intervention planning – which are shared processes pursued by emphasising consultation, agreement and legitimacy (fair, moral, justified treatment of children).

Intervention: All intervention in the formal YJS should be child-friendly and child-appropriate. This means that policy-makers and practitioners should prioritise children’s participation and engagement in the design, delivery and evaluation of services.

The YJS should embed a systems management approach to intervention planning that is evidence-based (not pre-judged, pre-formed, ‘off the shelf’ interventions) and achieved through partnership between children, practitioners, policy-makers and researchers.


Sometimes intervention is unavoidable.

Such consultative and inclusionary ways of working with children in the YJS have been found to be effective internationally in relation to promoting positive outcomes (e.g. children’s perceptions of the increased legitimacy of their treatment, increased access to their entitlements) and decreases in the negative outcomes targeted by interventions (e.g. offending, reoffending, antisocial behaviour).

The new AssetPlus framework for assessment and intervention in England and Wales has the makings of such an approach to the extent that it promises more consultation with children in the YJS, more practitioner discretion, a more holistic understanding of children’s lives and more appropriate, effective interventions as a result.

“What CFOS requires to make it work is a change of attitude and practice…”

A CFOS approach to youth justice founded on positive promotion, diversion and intervention can be achieved within current legislation in England and Wales (along with other countries internationally). It does not require seismic policy shifts or huge injections of money in the short-term. What CFOS requires to make it work is a change of attitude and a change of practice.

A Children-First model for our time

CFOS is not a buffet from which to select some elements, whilst others can be ignored. The model is a whole child, holistic, coherent approach. Every component should be executed as assiduously and effectively as any other. CFOS and the interventions it delivers are child-friendly and child-appropriate, working to the central principles that prevention is better than cure and that children are part of the solution, not part of the problem.

“CFOS is a new way of framing and understanding the lives of these children”


Justice Minister Dominic Raab. CFOS could provide the answer for youth justice reform. Image courtesy of Wikipedia.

As academics, we are often criticised (notably by politicians and frustrated policy makers) for being so critical, for pointing out what is wrong with the system, for highlighting its flaws and failings, for being against everything, but for offering nothing by way of an alternative. Through CFOS positive youth justice, we are engaging pro-actively in the debate about how we should respond to children in the YJS.

CFOS is our attempt to structure the answers to the question concerning the nature, intensity and timing of intervention in the YJS and a new (principled, progressive, pragmatic, positive) way of framing and understanding the lives of these children. With a new UK Government and a new Justice Minister inevitably looking for potential areas of youth justice reform, we offer a solution: CFOS.


CoverKevin Haines’ and Stephen Case’s book, Positive youth justice: Children first, offenders second, is available to buy from the Policy Press website. You can also follow Stephen on twitter @SteveCaseCrim and join the Positive Youth Justice Facebook group.

Don’t forget Policy Press newsletter subscribers get a 35% discount when ordering through our website. If you’re not a subscriber yet why not sign up here today and join our Policy Press community?

The views and opinions expressed on this blog site are solely those of the original blogpost authors and other contributors. These views and opinions do not necessarily represent those of the Policy Press and/or any/all contributors to this site.

Recording the labours of the ingenious: 350 years of the scholarly journal

In this blog post, Kim Eggleton, our Journals Executive, takes a look back at the 350 year history and exciting future possibilities for the humble Journal.

Kim Eggleton, Journals Executive

Kim Eggleton, Journals Executive

2015 marks the 350th anniversary of the scholarly journal. Can you believe that, 350 years? Think where we’ve come from there. There are now arguably too many journals to choose from!

There are even tools and businesses dedicated to helping researchers find the “right” journal for them. While the exact number is up for debate, there were estimated to be more than 28,000 active scholarly peer-reviewed journals in existence in August 2012, collectively publishing about 1.7–1.8 million articles a year (Ware and Mabe, 2012).

There’s a journal of everything now. Want to know more about chips? Try the American Journal of Potato Research. Wondering what the music of Ancient Greece was inspired by? Try Greek and Roman Musical Studies. Interested in what causes dandruff? Read the International Journal of Trichology. Any viewers of Have I got News for You know this list could go on and on. But this tells us something…

Someone was onto something 350 years ago.

The first journal ever published began as a bit of a private project for Henry Oldenburg, the then Secretary of the Royal Society. Henry wanted to create a kind of collective notebook between scientists, and came up with Philosophical Transactions. The aim of the journal was to give “some accompt of the present undertakings, studies, and labours of the ingenious in many considerable parts of the world”.

The journal was published pretty much on a monthly schedule, and Henry himself put out 136 issues before his death in 1677. It was only taken over by the Society in 1752, until then all financial and editorial responsibility was that of the Secretary of the Society. At the end of the 19th century journal was divided in to two, such was the increase in and demand for scientific discovery. Philosophical Transactions A covered the physical sciences and Philosophical Transactions B covered the life sciences. An exhibition of the treasures relating to the first ever journal is currently on at the Royal Society in London, and runs until next Tuesday.

“Most academic journals now have double-blind peer review -the author doesn’t know who the reviewer is and vice versa.”

Peer review as we know it today has its roots in this journal, although until the end of the 19th century, peer review was only conducted by the Editor in Chief, or perhaps a small team of advisors – and they knew the identity of the author. Most academic journals now have double-blind peer review, meaning the author doesn’t know who the reviewer is and vice versa.

Nowadays peer review is an accepted part of academic life, and journals can reach out to any qualified academic in the field to ask them to complete a review. Lots of researchers will receive a number of requests to review papers each week, and peer review itself is often described as system now in need of an overhaul.

A Brave New World

There have been many, many changes in journals-land since Henry started Philosophical Transactions – some small, some colossal. The upscaling (and economies of scale) of production thanks to industrial sized printing presses in the 1900’s. The personal computer. The move to online – not only for access, but for submission and review. The Big Deal. Open Access.

Henry Oldenburg would hardly recognise the moden Journal and its accompaniments.

Henry Oldenburg would hardly recognise the moden Journal and its accompaniments.

Could Henry ever have conceived of something like PLOS ONE or GoogleScholar? And that’s keeping things relatively traditional. What about the other innovations in research dissemination, like FigShare? And the ways of measuring impact using tools like Altmetrics and Kudos? Researchers are under pressure now not only to study and publish, but to prove that what they publish makes a difference.

“I can’t imagine my life without Editorial Manager.”

The future

Things are moving very fast now for journals, and I’m sure that at the 400th anniversary of Philosophical Transactions, things will be unrecognisable again. There are new ideas and projects being launched all the time – and this is a very healthy thing. A small but personal example: I use Editorial Manager every day to keep an eye on the papers coming into all our journals. I can’t imagine my life without it – I’d constantly be on the phone, I’d have lists coming out of my ears, I’d have to carry all my notes around with me if I went away on business… it’s a horrible thought. I’d certainly lose something, if not many things – including my mind. Many resisted the idea of an online submission system at first, but it’s made a big improvement in time to publication, peer review transparency, and ultimately author satisfaction.

Science has taken thousands of great leaps forwards since Henry Oldenburg started his “collective notebook”, but so has the notebook itself. While I won’t be around to attend the 2515 exhibition, I’m certainly intrigued to see what happens next…


Ware, M. and Mabe, M. 2012, The STM report: An overview of scientific and scholarly journal publishing, 3rd edition,

Larsen PO, von Ins M. The rate of growth in scientific publication and the decline in coverage provided by Science Citation Index. Scientometrics 2010; 84(3):575-603. doi:10.1007/s11192-010-0202-z


The politics of emotion: What we can learn from responses to child abuse and social work

In this blog post (originally posted on Discover Society, February 01, 2015), Senior Social Work Lecturer Jo Warner (University of Kent) discusses the political and social impact of media responses to child abuse.


Jo Warner, Social Work Lecturer

For some 40 years, responses to the deaths of children from abuse and neglect have been characterised by increasing levels of anger and hostility towards the social workers involved.

In the UK, this hostility reached its zenith in late 2008 with political, media and public responses to the death of Peter Connelly (‘Baby P’). When The Sun newspaper declared ‘Blood on their hands’ on its front page of 12th November 2008, it was not referring to Peter Connelly’s killers but to the professionals involved in the case. Wide-ranging reforms to social work followed and intense debate about the case continues. The ‘Baby P effect’ is reflected to some degree in the numbers of children in care, which have increased significantly since 2008 and are now at their highest level for twenty years. Continue reading ‘The politics of emotion: What we can learn from responses to child abuse and social work’

Food for thought for Father’s Day

Esther McDermott

Esther Dermott

Esther Dermott (University of Bristol) and Tina Miller (Oxford Brookes University) are the guest editors of a forthcoming special issue on contemporary fatherhood for Families, Relationships and Societies. A number of the articles from the issue have been made free in the lead up to Father’s Day in the UK.

From personalised beer to racing driver experiences – a full range of gender stereotypical presents are available branded as perfect for Father’s Day. So, it might be tempting to see the growth of Father’s Day in the UK (June 21st this year) as little more than another marketing opportunity; one that doesn’t say much about everyday fathering and certainly doesn’t give the impression that we have radically changed our ideas about fathers.

“men who are doing things differently have a higher profile”

Looking back over the last 40 years of research on fatherhood, there is evidence that things are different now. We can point out generational shifts in how men ‘do’ fatherhood; dads have substantially increased the amount of time they spend with their children and almost all now attend births and take time off work when a baby is born. It is also the case that men who are doing things differently have a higher profile, witness for example of blogs of stay-at-home dads and single fathers. And these changes are Continue reading ‘Food for thought for Father’s Day’

Book Aid International

In this blog post, Nick Levett, a volunteer at Policy Press highlights the impact of Book Aid International, a book-distribution charity that Policy Press have recently had the pleasure of donating over 28,000 books to.

Book Aid International is a fantastic charity that has donated over 31 million books to libraries in Africa, as well as training local librarians. In this blog post, I’d like to draw more attention to the human impact their projects have had, their history, and how you can help Book Aid continue its invaluable work.

Moses Mwandihi is the librarian at the Kisumu Provincial Library, which for many years has received books from Book Aid International. The picture Moses paints of the availability of books in schools in the region is dire: Continue reading ‘Book Aid International’

Growing injustice: six myths about inequality

final-cover-photoby Danny Dorling

Originally published on the New Statesman Politics Blog, The Staggers, 1 June 2015. Read the original article here.

We need to see things as they are, not as a few with great wealth would have the rest of us believe.

We used to say that most people don’t know how the other half lives; in the UK that has changed. Our society can no longer be meaningfully divided into two halves. Most of us have little understanding of the lives in the tranche just above or below us, and those people have little understanding of the tranches above and below them and so on. We live in different worlds. Most people find it difficult to believe that some people who have an income ten times higher than theirs, when asked, say that they are finding it difficult to manage financially. Continue reading ‘Growing injustice: six myths about inequality’

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