Feature

The heart of the matter

The government’s new public health white paper sets tough new targets to prevent coronary disease and other major killers – but does it address the income inequality at the heart of the health divide? Wendy Moore reports

Placing defibrillators in public places and teaching 11-year-olds basic first aid are sure to grab headlines, but they will do little to narrow the widening health divide between Britain’s rich and poor.

The Government’s long-awaited public health white paper, launched in July, pledges to save 300,000 lives from Britain’s major killers – heart disease and stroke, cancer, accidents and suicide – by 2010 and to reduce health inequalities. Training members of the public to use defibrillators in airports, rail stations and shopping malls, and taking first aid lessons into schools, were the main aspects fed to the media by Downing Street spin doctors launching the crusade.

Public health campaigners have broadly welcomed the strategy, Saving Lives, with its commitment to tackle poverty. But they are worried that the Government’s disease-based approach may end up actually increasing the health divide.

‘The Government is moving in the right direction and saying all the right things,’ says Donald Reid, joint chief executive of the UK Public Health Association. ‘But there are reservations about what is not in there.’

Concerns centre on the Government’s failure to set a national target to reduce health inequalities. While there are clear targets and action laid down for the four main goals, there is no target or deadline for reducing the health gap.

The Government has repeatedly pledged to tackle inequalities and spells out action already taken towards this aim in its response, published alongside the white paper, to last year’s Acheson inquiry. But while these measures – like the minimum wage, the working families tax credit, increased child benefits, job creation and investment in housing – are all warmly welcomed, there is no mention of redistributing wealth through taxation, which public health activists argue is the most important step towards ending inequalities in health.

‘There is this worry they are not as serious as they might be over the gut issue of inequalities and poverty,’ says Reid. Without clear targets he fears health service managers will still be forced to put cutting waiting lists before tackling the health of the poorest.

Deaths from cancer, heart disease and stroke, accidents and suicide are all declining already, he explains, but they are all decreasing faster among the more affluent because middle class people have adapted to healthier lifestyles by quitting smoking, cutting alcohol intake and eating better diets. Heart disease among middle class men under 65 has virtually disappeared.

It is poor people who are the main victims of the four killers. The white paper points out that unskilled working men are three times more likely to die from heart disease, twice as likely to die from cancer and four times more likely to commit suicide than their professional counterparts. Children under 15 from unskilled families are five times more likely to die from accidental injury and 15 times more likely to die in a house fire than those from professional families.

Experts still debate the reasons for these differences but it is clear that poverty, stress caused by deprivation, and lifestyles are major factors. Three times as many men in unskilled jobs as in professional jobs smoke and rates are also particularly high among single mothers.

‘It is very, very difficult to persuade anyone in deprived situations to give up smoking,’ says Reid. ‘Targeting smoking is such a waste of time.’

Anti-smoking efforts are far more effective at persuading middle class people to quit – thereby widening health inequality. The same goes for campaigns targeting diet, exercise and alcohol. The upshot is that the four targets may be met through better middle class health, while poorer people’s health slips further down and the health divide widens, argues Reid.

The key, he says, must be providing people in deprived situations with hope and ambition – so that changing lifestyles is worthwhile. That means lifting people out of poverty, providing young people with a realistic chance of employment, improving the environment, housing and transport. Crucially, says the UKPHA, wealth needs to be redistributed in order to redistribute health.

Other analysts agree. Margaret Whitehead, professor of public health at Liverpool University and a member of the Acheson inquiry, says research shows people on low incomes pick up the same health education advice on smoking as middle class people and many try to quit. ‘But the fact is it is very much more difficult to quit if you are living in hardship and struggling from day to day.’ To successfully give up smoking people need optimism, not stress.

Similarly, people on low incomes are well aware of advice on diet but lack sufficient money to buy the right food. Researchers have found that current levels of benefit are inadequate for the essential pre-requisites of good health, like fresh fruit and vegetables, says Whitehead. It is still important to put out health information giving the right messages, she believes. But this must go hand in hand with other measures, like raising benefit levels.

Suzi Leather, honorary research fellow at Exeter University and chair of a planned healthy living centre incorporating a community cafe, believes raising benefit levels is the single most important factor in improving poor people’s health.

‘Just telling people what to eat doesn’t work. There is not a great difference in knowledge about healthy eating. It is not ignorance,’ she says. Many factors prevent poorer families eating well, including income, access to cheap food and culture. ‘It is difficult to change your diet and involves experimentation. Healthier diets cost more money and they cost more in deprived areas than non-deprived.’

The Government is right, she believes, to tackle health inequalities on several fronts at once. Raising income is crucial, but so is working on healthy eating messages in schools and supporting community projects to help people cook healthy meals with limited resources.

The British Heart Foundation has also welcomed the broad-based approach, pointing out that heart disease is also more common among some ethnic minority groups and people with lower educational achievement. Work in schools will be important, says assistant medical director Vivienne Press.

Other aspects of the white paper have also been criticised. The UKPHA has complained that the strategy is too centred on health services, at the expense of local authorities. The Local Government Association agrees, pointing out that disease-based targets could discourage local authorities from playing a lead role in public health aims.

But there has been wholehearted support for much of the strategy. Plans to introduce legislation allowing the fluoridation of water where local people want it – subject to a scientific review of evidence on safety – have won wide support. The National Alliance for Equity in Dental Health, which includes more than 40 health organisations, says fluoridation could save hundreds of thousands of children from the pain and suffering of tooth decay and extraction.

Proposals to boost the status of the public health workforce, emphasising the skills of health visitors, midwives and school nurses and creating a new consultant post for non-medics, are also popular. And broad support has greeted plans to replace the Health Education Authority with a new Health Development Agency, charged with raising standards in public health and collating evidence about what works best in health promotion. The new HDA – effectively a National Institute for Clinical Excellence for public health – will have the same £30m budget as the HEA but a slimmed-down staff from the current 250 workforce.

Yve Buckland, who chairs the HEA and will also head the new body when it goes ahead in January, says: ‘It is quite a radical transformation.’

The HDA will channel more funds into researching and disseminating evidence and less into high profile campaigns which, she says, give out ‘middle class messages to middle class people’. It will work with the new regional public health observatories, as well as other agencies, especially local authorities. Herself the former deputy chief executive of Nottingham city council, she is keen to harness councils’ work in areas like regeneration.

Whereas the HEA has focussed largely on lifestyle, the HDA will grapple with the root causes of ill health, says Buckland. But a headlong clash with Government over demands for instant wealth redistribution seems unlikely. The HDA will work with Government, she stresses.

Simply tackling poverty is not the only answer, she argues. ‘You can raise someone’s income, but if they still live in fear of crime they will have high stress levels and be more likely in the long term to have poorer health.’ She adds: ‘I think there is a real drive to find a third way of doing it’.