Fairness and health equity

Achieving health equity (the absence of health inequalities between different groups in society) is a matter of fairness.

There is a 'social gradient in health': the lower a person’s social position, the worse his or her health. People with different levels of income and other social circumstances experience avoidable differences in health, with the better off living longer lives in better health than the disadvantaged. This is unfair. The relationship between social inequality and health inequality is so strong that the magnitude of health inequalities is a good marker of progress towards creating a fairer society.

Part of this is about the delivery of healthcare: everyone in the UK should be able to access high-quality care to support them to attain mental and physical health and wellbeing. But the more important issue is tackling the social determinants of health, the non-medical factors that influence health outcomes. These are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. Tackling these broader issues is the best way to prevent ill-health and promote wellness and wellbeing. Prevention is cheaper than cure, and there is both an inarguable moral case and a compelling economic case for investing in health equity and in the social infrastructure that enables it, and which supports individuals in living healthy lives.

The pandemic reinforces what we already know. We can’t keep people healthy if they don’t have a roof over their head and food on the table.

Bechara Choucair, Chief Health Officer, Kaiser Permanente

Tackling health inequalities

Unfair health outcomes nearly always result from unfair access to opportunities and unfair inequalities in our society. According to the World Health Organisation, sectors outside health have a bigger impact on population health outcomes than the health sector itself. This is not widely understood by the public, despite the excellent work of Sir Michael Marmot and others. Tackling health inequalities does not require a separate health agenda so much as a broader societal agenda. We need to focus on all of the 'social determinants of health', including income, housing, upbringing, education, work and the environment, and focusing on improving opportunities and living standards for everyone (the idea of ‘proportionate universalism’, based on universal rather than targeted interventions, but with a scale and intensity that is proportionate to the level of disadvantage).

The more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus.

The healthcare system

The NHS (and local government and voluntary sector) can also play a key role, by investing more in preventing ill-health and tackling inequalities in access to healthcare services, and ensuring that the availability and quality of healthcare and health promotion services in deprived areas (or targeted at disadvantaged groups) is as high as in more prosperous parts of the country. Funding for prevention and tackling health inequalities could be freed up by improving productivity and reducing costs in the NHS (in areas such as contracting, procurement and reducing agency costs). The NHS should continue to contract the private sector to deliver some clinical and non-clinical services as long as they are timely, free at the point of use, high quality and delivered efficiently.

What needs to change

Given that most actions to reduce unfair health outcomes involve addressing non-health issues such as income inequality, housing and education, most of the changes proposed below are beyond the scope of the NHS. However, the NHS should also be investing more in health promotion and the prevention of ill-health, including promoting healthy diets and exercise (i.e. the demand side), as well in ensuring that any inequalities in the delivery or availability of healthcare services (the supply side) in different regions or to different groups are tackled.

The Marmot 2021 report on COVID (Build Back Fairer) repeats key themes of the 2010 and 2020 reports on health inequalities, arguing for seven priority areas for action:

  • Reducing inequalities in the early years (including by increasing spending on years provision to improve availability and quality, and increasing pay for childcare workers)
  • Reducing inequalities in education, with a focus on equity in funding decisions and increasing attainment levels (including by restoring per-pupil funding, increasing access to laptops, making exam grading more equitable, rolling out catch-up tuition, providing additional support for pupils with special needs and excluded pupils)
  • Increasing fairness for children and young people, with a focus on poverty, mental health and education, employment and training (including by reducing child poverty levels to 10%, improving mental health support in schools, increasing the number of training schemes and apprenticeships, and increasing funding for youth services)
  • Creating fair employment and good work for all, by providing a more generous minimum wage for everyone in work and a minimum income for those not in work, tackling poor-quality work and precarious employment, and improving work-life balance.
  • Ensuring a healthy standard of living for all, by putting health equity and wellbeing at the heart of local, regional and national economic planning and strategy, making the tax and benefits systems more progressive and the latter less punitive, and eradicating food poverty.
  • Creating and developing healthy and sustainable places and communities, by increasing local government funding in deprived areas, tackling air pollution in deprived areas, building more good-quality homes that are affordable and environmentally sustainable, increasing support for those in the private rented sector, reforming council tax, reducing homelessness and extending protection against eviction.
  • Strengthening ill health prevention, by building a public health system that focuses on acting on the social determinants of health and health inequalities, with more funding (0.5% of GDP, with spending focused proportionately across the social gradient).

A recent COVID impact report by the Health Foundation (Unequal pandemic, fairer recovery) outlined the opportunity for "a new settlement between the state, individuals, the third sector and business" with the goal of improving health and reducing inequalities at its centre. It suggested that action was needed in two areas:

  • Immediate action to address the harm caused by the pandemic and prevent longer term scarring effects. This includes tackling the health care backlog, increasing mental health support to help people back into work, protecting family finances, creating jobs, and ‘catching up’ education and training.
  • Building resilience for the longer term. This includes putting in place an adequate safety net to cope with future income and health shocks, providing greater protections for low-paid workers, designing better quality jobs, creating stronger communities and investing in higher quality public services to put prevention first through the government’s levelling up agenda.

It also suggested that change is not just about additional spending, and that the government can place a greater focus on using resources wisely, joining up initiatives across government and taking a ‘prevention first’ approach to enable better spending through local government. It recommended that in making decisions about allocating spending, greater weight needs to be placed on longer term, preventative measures and health and wellbeing gains.