Are health inequalities still a policy priority in the UK? Reflecting on post-1997 experiences and imagining some alternative scenarios

After 18 years in the policy wilderness, Labour’s 1997 election victory placed health inequalities firmly on the UK policy agenda.  Officially at least, health inequalities have remained a policy priority ever since.  Yet, the social gradient in health has remained stubbornly persistent and, in the context of the current welfare reforms, it seems necessary to ask whether health inequalities really are still a policy concern.

Since 2003, I’ve been interviewing individuals involved in public health research and policy across the UK (civil servants, ministers, politicians, individuals working at large charities and other campaigning organisations, journalists and researchers working in universities, the public sector and think tanks).  A consistent theme across nearly all of the 125 interviews I’ve now undertaken (and particularly the 67 post-2010 interviews) has been a sense of intense frustration with the lack of progress in reducing health inequalities.  This has often been accompanied by pessimistic projections about the likelihood of future success and concern that political interest in health inequalities is waning (especially in England).  In what follows, I use the interview data to consider the following three questions:

1)      Why do so many people involved in health inequalities research and policy seem to have such a pessimistic outlook about the prospects of success?

2)      Are health inequalities really slipping off policy agendas in the UK?

3)      What can be done to ensure health inequalities remain a policy priority across the UK?

1) Why do so many people involved in health inequalities research and policy seem to have such a pessimistic outlook about the prospects of success?

A key reason for people’s pessimistic outlook was that almost all of the 67 individuals I’ve interviewed since 2010 said they believed current economic and welfare policies were likely to widen health inequalities.  Most found it hard to believe that a government seriously committed to reducing health inequalities would implement such policies.

Second, over half of the interviewees described feeling that the UK’s social and political context stymies efforts to address health inequalities.  This belief stemmed partly from a sense that the public are relatively unconcerned by health inequalities (or, indeed, other kinds of social and economic inequality) and partly from broader concerns with the growing material inequalities arising out of a consumer-capitalist culture.  These factors combined to create a sense that efforts to reduce health inequalities are constantly being constrained by a hostile, unassailable context.

Finally, most people felt the ‘solutions’ to health inequalities remained unclear.  Without consensus around what needs to be done to tackle health inequalities, some interviewees (particularly those in campaigning organisations) felt it was difficult to keep promoting the issue to political and policy audiences.

2) Are health inequalities really slipping off policy agendas in the UK?

Although the current situation is different from the Thatcher-led government’s refusal to discuss health inequalities, none of the interviewees I spoke to believed that any of the UK’s mainstream political parties were currently prioritising health inequalities.  Whilst the Conservative-Liberal Democrat coalition has made some nods towards health inequalities (dedicating a chapter to the issue in the 2010 Public Health White Paper and providing funding for Michael Marmot’s UCL Institute for Health Equity), several interviewees reported having encountered ministers who ‘didn’t agree with / believe in’ the 2010 Marmot Review.  Meanwhile, some Labour politicians reported a sense of embarrassment around health inequalities, with one MP explaining, “I think that it’s felt that because we didn’t do as well as we should have done, politically it’s one we need to not talk about, it’s not going to help us.”  This leaves a worrying gap in the party political landscape around health inequalities, at least in England (the situation is somewhat different in Scotland and Wales, where political support for more radical responses to health inequalities is evident, but where powers to take action remain limited).  Advocates and campaigners for reducing health inequalities were also distinctly few and far between  Whilst there are some active online groups (e.g. the Politics of Health Group and the Health Equity Network), it is much harder to identify organisations that consistently and actively campaign to reduce health inequalities.  Both the UCL Institute for Health Equity and the Equality Trust have the potential to take on this role but there is little evidence in the interview data that either is yet doing so.  Meanwhile, none of the large, health- focused campaigning organisations in which I interviewed people seemed to be prioritising health inequalities. It is therefore unsurprising that not a single one of the 60 journalists, policymakers and campaigners I’ve interviewed since 2003 has been able to name any organisations actively and consistently campaigning to reduce health inequalities.  This places the issue of health inequalities at a marked disadvantage relative to many other public health concerns, such as tobacco and alcohol control, where advocacy/lobbying is far more apparent.

3) What can be done to ensure health inequalities remain a policy priority across the UK?

There are no simple answers to this question but interviewees’ reflections suggest three strands of work are required.  First, we need to develop coherent policy ideas for addressing health inequalities. This won’t be easy given that, as Geoff Mulgan recently reflected, researchers often struggle to move beyond describing the world as it is to imagining the world as it could be.  Indeed, some of the people I spoke to (in research and policy) questioned whether it was the job of health inequalities researchers to come up with policy solutions, but if researchers don’t attempt this, who will?

Second, those seeking to reduce health inequalities need to do more to understand policy processes and means of achieving policy change.  This includes paying more attention to the ideas and interests currently shaping UK policies (often in ways which exacerbate health inequalities). Here, we can take inspiration from tobacco control, where a concerted effort has been made to understand the ways in which pro-tobacco interests think and operate.  It will, without doubt, be more difficult to study the complex array of actors and interests involved in the policies that exacerbate health inequalities but it is no less important.

Finally, we need to get better at working collaboratively and developing coalitions of actors seeking to reduce health inequalities.  Popular theories of policy change suggest that ‘advocacy-coalitions’ of actors from a wide range of sectors are key to understanding how major policy shifts occur.  Yet, for the moment, debates and events relating to health inequalities often seem to depend on initiatives taken solely by researchers and individuals working in the civil service or the wider public sector.  To take advantage of the multiple dimensions of policymaking processes, future debates about health inequalities must do more to engage with politicians, trade unions and civil society organisations.

Some of this research is discussed in more detail in a new book by Katherine Smith, ‘Beyond Evidence-Based Policy in Public Health: The Interplay of Ideas’ (Palgrave, 2013). Research exploring the role of advocacy within public health is ongoing and supported by an ESRC grant entitled ‘A Risky Business? The Politics of Knowledge Transfer in Public Health’