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.
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.
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.
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