The existence of inequalities should come as a surprise to no one and they regularly make the headlines in the UK: gender pay gap, disabled people disproportionately affected by cuts to welfare benefits; unprecedented increase in homelessness and differences in life chances and mortality rates depending on whether you live in the north or south of the UK. How refreshing it would be to see a reversal of fortune: women and men on equal pay; massive reduction in homelessness and less people being evicted than ever; welfare benefits changes welcomed by disabled people as enabling them to have the choice and control they demand and mortality rates no longer affected by your postcode. Whilst it is tempting to think that the media always like a negative headlines the pervasive and persistent nature of social inequalities are well supported by robust evidence. Since the inception of the NHS seventy years ago, and the publication of the Black Report over forty years ago, social inequalities have provided a focus for health policy in the UK and internationally. The resounding message is that poor health reflects socio-economic disadvantage and that to have an impact on health inequalities these social determinants need to be addressed and start early with children to maximise life chances. In our work for the University of Birmingham Commission on Mental Health, it is very evident that material and environmental circumstances and socio-economic disadvantage are associated with enhanced risk of all types of mental health difficulties from depression to psychosis. The message that one in four of us experience poor mental health in any one year in seeking to reduce mental illness related stigma obscures the evidence that the risks of poor mental health are not evenly spread and that for some groups the risk are much higher, fuelled by the lack of appropriately designed services that take account of our population’s diversity and understand how power and privilege are distributed.
So if the relationship between inequalities and different aspects of health is so well established and recommendations to address them regularly promoted since the Black report by the Acheson Report, the Marmot Review, World Health Organization amongst others, all convey similar messages we need to be asking why such inequalities persist. There are potentially a number of explanations. First, it is likely that change is happening but will take time because social inequality is deep rooted and the power dynamics are nuanced and covert. There are undoubtedly positive initiatives taking place, as for example the recently established Women’s Mental Health Taskforce but such initiatives are often short-term, the action that is required is not sustained over time and there is a resistance to learning from previous initiatives. Second, the focus on inequalities is competing with apparently more pressing priorities – winter pressures, funding constraints and rapid technological advances for example, although health inequalities play a role here too. Third, increasingly explanations of health inequalities focus on lifestyle issues and behavioural change rather than their underpinning social determinants with an associated lifestyle drift contributing to widening inequalities. Fourth, our research endeavour and development of new knowledge and practice in this sphere does not adequately address inequalities, with some groups explicitly and routinely excluded – for example people from black and minority communities, older people or people with mental health problems or complex co-morbidities. Thus the conclusion that our social norms and policy practices tolerate inequality and promote the unfair distribution of resources necessary for health is inescapable. We only have to look around us to see that this is the case.
We, therefore, have a state of affairs where tackling inequalities is an add-on to mainstream activity rather than the golden thread, with all policies being evaluated for their impact on health inequalities and strong leadership and governance arrangements to ensure that appropriate action is taken to ensure that these are addressed. Universal health coverage provides a foundation for this but additional action is needed to narrow the gaps in access to effective and appropriate treatment and outcomes in health status that we seek. Arguably the Equality Act 2010 provides a vehicle but its application to health inequalities appears weak and rather than facilitating intersectionality, it has been criticised for masking inequalities for specific groups by bringing them together, thus, rendering the specific inequalities that rise as a consequence of race, gender, sexuality, disability etc. less visible. Action following the Beijing Platform in 1995, which introduced the concept of gender mainstreaming to address deep rooted gender inequalities in an international context is instructive here. The evaluation of progress has demonstrated that whilst gender, as do other dimensions on inequality, need to be a focus for analysis and policy in terms of access to health care and outcomes, there is also a need for specific programmes that focus on addressing the source or manifestation of these. For example, initiatives that tackle domestic violence, empower women to take action to protect and promote their own health and take up leadership in their communities. Despite these, progress has been slow and there are now calls for this to be accelerated. Legislation and policy will not have a radical impact on health inequalities without the co-production of solutions with groups and communities that are disadvantaged by our current social norms. Initiatives, such as Black Thrive in Lambeth, a partnership between statutory and community organisations, are to be very warmly welcomed as they focus on unequal health outcomes and seek to address the underpinning cultural and social basis for health inequalities. They represent a holistic and systems wide approach with radical action to achieve health equality clearly in their sights. As John Ruskin argued more than 150 years ago, ‘there is no wealth but life’, we urgently need political commitment and investment at national and local levels to addressing the root causes of health inequalities to transform fortunes for us all.