The explanations for the ‘widening gap’ in health inequalities over the last two decades.
The following assignment aims to discuss and explore the subject of health, and the various possible explanations for the so-called ‘widening gap’ in health inequalities, which has become increasingly evident over the last two decades. The term ‘health’ has numerous and varying definitions; however one widely accepted definition, which comes from the World Health Organisation (2005) states that:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
In this definition the emphasis is placed on the entirety of the individual, and appears to encourage a holistic approach to the provision of healthcare, as opposed to a more medical-based reductionist approach. Lewisham Primary Care NHS Trust (2004) define the term ‘health inequality’ as:
“(…) The difference in health experiences and health outcomes between different population groups. They can be defined by socio-economic status, geographical area, age, disability, gender or ethnic group.”
This clarification of the term ‘health inequality’ describes a number of variable factors, which are used commonly to measure health inequalities across population groups. Adler et al (1993) explains that socio-economic status is a “strong and consistent predictor of morbidity and premature mortality”. Graham (2005) reinforces this, stating that socio-economic status is a “fundamental determinant of health”.
Catford (2002) states that the problem of health inequalities is a prominent one, which is found worldwide in all developed countries. Health inequalities have existed and been acknowledged for a number of centuries (Marmot, 2001) and, in addition to this, Illsley (1999) reports that the long-standing problems and difficulties posed by health inequalities in the United Kingdom were expected to “be reduced or even eliminated” after the establishment of the National Health Service; however the Department of Health (2005) reports that health inequalities are “stubborn, persistent and difficult to change”, and that “the health gap is still continuing to widen”.
The problem of health inequalities in the United Kingdom has been explored and researched intensively within two government reports, the Black Report (1980) and the Acheson Report (1998); as a result of these reports, “reducing inequalities in health is now a matter or urgent public policy concern” (Carlisle, 2000). Furthermore, Waterston et al (2004) reinforce this, detailing that reducing health inequalities is currently an “important component of UK health policy”.
Due to the complexity and nature of this subject, there appear to be a number of causes and explanations for the ‘widening gap’ in health inequalities in the United Kingdom. Carlisle (2000) suggests that “official neglect” on the part of the government has been instrumental in allowing the health gap to widen. Marmot (2001) supports this, explaining that the Conservative government of the 1980s “dismissed” the findings of the Black Report. Essentially the “rejection” of the Black Report by the government prevented a proactive stance in confronting the health inequalities problem from being taken (Marmot, 2004). Raphael (2001) agrees with this, reporting that the gap in health inequalities had grown “systematically” over the two decades of Conservative rule in the United Kingdom. However, Marmot (2004) states that the New Labour government of 1990s intended to place a larger focus on tackling the health inequalities problem, which was achieved with the commissioning of the Acheson Report; set up to provide “a key influence” on public health policy in the United Kingdom (BBC, 1998). Despite this Raphael (2001) reports that the initiatives of New Labour “have done little to narrow the gap” in health inequalities.
Black et al (1999) state that the Acheson Report “echoes the findings” of the Black report, suggesting that health inequalities are largely influenced by socio-economic status, and “that the gap in inequalities in health has been steadily increasing”. The Acheson Report suggests that inequalities in health stem from socio-economic factors (Marmot, 2004).
Black et al (1999) highlight a number of contributory “influences” towards the ‘widening gap’ detailed within the Acheson Report, such as; the ceasing of the association between benefits and earnings, “restraints” on child benefits, and the termination of single parent benefits. The role of these factors in the widening of the health inequalities gap is acknowledged by Silventoinen and Lahelma (2002) who state that “poor childhood living conditions damage health”, and can potentially promote the development of health problems later in life. Waterston et al (2004) reinforce this, explaining that the increasing gap in health inequalities is “particularly evident among children”. Therefore, the Acheson Report suggests that financial benefits are increased for poorer families with young children and babies, with the aim of lowering poverty and reducing long-term health inequalities (BBC, 1998). There is clearly a need to increase benefits for poorer families (Black et al, 1999); this need is supported by the BBC (1998) who report that babies from families “in lower social groups” tend to have lower birth-weights, which is strongly associated with increased instances of “heart disease and related illnesses in later life”.
Adler et al (1993) acknowledge that the lifestyle and behaviours adopted by an individual, such as “smoking, diet, and lack of exercise” have the ability to impact upon their health; health inequalities across socio-economic groups are influenced by “differences in lifestyle” (Catford, 2002). Carlisle (2000) states that the ‘widening gap’ in health inequalities is facilitated by the “unhealthy lifestyles and choices” of individuals within socio-economic groups. The Acheson Report details that people from lower socio-economic backgrounds are “more likely” to smoke and drink heavily than those from wealthier, higher socio-economic groups (BBC, 1998); Ewles and Simnett (1992) and Adler et al (1993) both suggest that these habits could be used as “coping” methods to combat the stress of living at the bottom of the socio-economic hierarchy. However, the BBC (1998) explains that since the Acheson Report a number of suggestions have been made and put forward, aimed at reducing inequalities in health, including; a “ban” on tobacco and cigarette advertising, “restrictions on smoking in public places”, an increase in tobacco and cigarette prices, and the availability of “nicotine replacement therapy on the NHS”.
Interestingly, Lipley (1999) and Lazenbatt et al (2001) both highlight the link between lifestyle and health inequalities, by drawing on the example of sex-workers and prostitutes in Belfast. It is reported by Lipley (1999) that health problems are abundantly high within this occupational group due to the risks of sexually transmitted infection, HIV and pregnancy.
Ewles and Simnett (1992) refer to instances of ‘victim blaming’ in cases such as this, whereby individuals are deemed responsible, and to blame for “their own ill-health”. Dee (2002) illustrates an instance of ‘victim blaming’, by stating that people who have “stupid accidents (…) are clogging up the NHS”, and that in order to make people more careful the NHS should not treat patients “if what happened was their fault”. This attitude is not conducive to solving the health inequalities problem, whereas Carlisle (2000) puts forward and suggests a possible solution, emphasising the potential that health promotion may have in “addressing health inequalities” through encouraging people to adopt a healthier lifestyle. Since the Acheson Report there has been demand for increased “funding for schools in deprived areas” in order to provide improved health education and health promotion to school children (BBC, 1998). However, Ewles and Simnett (1992) state that typically health promotion only reaches people from higher socio-economic groups who have enough time, money and education to access and utilise health promotion information; therefore this suggests that health promotion activities have only a limited ability to solve the health inequalities problem (Carlisle, 2000). Furthermore, poorer people from lower socio-economic groups are less likely to have access to health promotion information, and as a result are often less educated and less able to make healthier lifestyle improvements (Ewles and Simnett, 1992).
This lack of access to health promotion information, which is experienced by people of lower class and socio-economic status, may also provide an explanation for the findings of Adler et al (1993) who report that people from lower socio-economic backgrounds “appear to make less use of preventive health services”. This is reinforced by Chapman (2001) who states that working-class people are “less likely to take advantage of NHS facilities”, such as visiting their doctor and utilising “preventative medicine”.
In addition to this, the BBC (2002) refers to a “postcode lottery” in healthcare facilities; they go on to add that the standards and adequacy of GP services “is highly variable” within the United Kingdom. This is supported by Webb (2001) who states that “geographical and class-related inequalities in healthcare are found both nationally and locally”; this is likely to result from different health authorities spending “widely varying amounts” and having “different priorities” to one another. Furthermore, it is reported that in the more deprived “inner city areas” of the United Kingdom there is more likely to be a shortage of GPs and “poorer facilities” (BBC, 2002). Webb (2001) reinforces this, stating that less adequate healthcare provision is available in the poorer “working-class areas” than in the wealthier “middle-class areas”; this is evidence of the north, south and rural, urban inequalities in health, which are experienced across different socio-economic groups throughout the United Kingdom.
In conclusion, throughout my research and my reading around the subject of health and the ‘widening gap’ in health inequalities, it has become apparent that there are a multitude of socio-economic causes and factors, to take into consideration when attempting to explain the reasons for the ‘widening gap’ in inequalities in health over the last two decades. However, it is important to recognise that health inequalities have existed worldwide for many centuries.