Feature
Nasty, brutish and short—or healthy, wealthy and long?
Are Labour’s policies on wealth redistribution, employment and child poverty having any effect on health inequality in Britain? Richard Mitchell and colleagues examine the impact so far
When New Labour swept to power in 1997 it brought with it a stark contrast to Conservative thinking on wealth, health and social inequality. Suddenly, it seemed those in power understood that poverty was one of the primary drivers of poor health and that growing gaps between rich and poor, healthy and sick did matter.
The new government inherited a bad situation. The map overleaf shows the change in premature death rates (death before the age of 65) in each Westminster parliamentary constituency from the early 1980s to the early 1990s, taking age and sex of the population into account.
Maps are a good way to highlight inequalities in health because they reflect both spatial and social inequalities. Long-term processes tend to etch differences in wealth and opportunity into physical space, so that different parts of our towns, counties and country tend to contain relatively richer or poorer inhabitants. That is most of the reason why some places have relatively higher or lower death rates – geographic health inequalities tend to reflect socio-economic inequalities.
One of the most important elements in tackling health inequalities is recognising that wealth, partly determined by income and employment status, is a tremendously strong influence on a person’s chances of poor health and premature death.
Governments are in the unique position of being able to affect wealth distribution by using social and economic policies as levers with which to influence the population’s health (for better or worse). The map shows how powerful these levers can be, illustrating the legacy of policies in the 1980s and early 1990s, which fostered a widening health gap between employed and unemployed, rich and poor.
When New Labour took power, we were looking for macro-scale socio-economic policies that might make a real difference to health inequalities. Three such policies stood out: a commitment to eradicate child poverty; a commitment to attain full employment; and the intention to redistribute wealth (albeit by stealth).
Their advent presented us with something of a challenge: what do you do when the government promises to begin doing the things you have been calling for, and which you believe could help to tackle inequality? This question spawned our report for the Joseph Rowntree Foundation, Inequalities in Life and Death: What if Britain Were More Equal? In it we tried to demonstrate how great the gain would be in terms of reducing geographic health inequality and saving lives if Labour’s policies succeeded.
Our methods were complex but a guide is available in the technical report (www.social-medicine.com/jrf/jrf1.html). The basis was knowing how death rates related to characteristics of the population and then estimating the impact of each policy on those characteristics. We made sure our methods worked by confirming that they could account for the rise in inequalities during the 1980s. The ‘lives saved’ number we gave for each policy is the estimate of how many more people would survive past 65 if the policy aim were achieved.
We estimated that if full employment were attained, 2,504 lives a year would be saved among people aged between 15 and 64. That represents 2 per cent fewer deaths at these ages for men and women in Britain. We also found that the benefits would be concentrated in those parts of the country that were experiencing death rates higher than the national average, thereby helping to reduce geographical inequalities in mortality.
The effect of even a modest redistribution of wealth was found to be very large indeed. We estimated that 7,500 people aged under 65 would not die each year if material inequalities between occupational classes were to fall slightly. Again, the benefits would be concentrated in the areas that had higher mortality rates.
“Just under a third of all the boys who die in Britain each year might not die if childhood poverty were eliminated”
Results for the eradication of child poverty were startling too. Even though death is comparatively rare among children, we found that this policy would still save 1,407 lives a year. Just under a third of all the boys who die in Britain each year might not die if childhood poverty were eliminated.
So the models suggested a tremendous reward in terms of lives saved and reductions in geographical inequalities if these policy aims were met. It seems reasonable then to wonder how much progress has been made. One problem with measuring this is that premature mortality is at least partly a marker of long-term circumstances and so there can be a time lag between the success of the policy and a response in death rates. However, we can monitor whether these policies have had any effect on the characteristics of the population they were meant to influence. Are the poorer getting wealthier, is unemployment falling, and are children being lifted out of poverty?
Our data come from the British Household Panel Study (BHPS), which re-interviews a sample of people every year, allowing us to monitor what happens to them over time. This shows that unemployment rates have indeed fallen. In 1996 (the year on which our original study was based), 5.3 per cent of the BHPS respondents said they were unemployed. This rate fell steadily to 3.6 per cent in 1999, with a slight rise in 2000. The fall was particularly marked for men, from 7.2 per cent in 1996 down to 4.4 per cent in 2000.
What about children in poverty? The BHPS tells us that the percentage of households with children and a household income below 60 per cent of the national median value (a standard measure of poverty) fell from 25 per cent in 1996 to just under 21 per cent in 1999 (the most recent year for which we could measure income).
Measuring progress in the redistribution of wealth is slightly harder. Our report used social class as a proxy for material wealth so we have explored changes in household income levels among the social classes. We chose two measures of income change: change in real money terms, that is the average change in annual income expressed in pounds per week (dark bars on the graph), and the average year-onyear change as a percentage of income (light bars on the graph).
The dark bars show that the richest group (class I) has gained most in absolute terms. For every £1 a week of income the average social class V household received in 1999, a social class I household was receiving £2.29. That gap is 13p more than it was in 1996.
However, the light bars show that lower social classes are doing much better in relative terms – that is, their incomes have risen proportionally much more than the richer groups (although their wages were lower to start with). Is this evidence for a successful redistributive policy?
To be fair, the data do not permit a definitive conclusion since they only cover the years up to 1999 and New Labour was elected in 1997; many of their potentially most redistributive policies have only just come into effect (for example, the Working Families Tax Credit). However, on this crude preliminary evidence, our judgement for all three policies is that things have been moving in the right direction.
Despite the progress, some subtle shifts in government thinking have occurred. Its approach to ‘health’ has become somewhat obsessed with the NHS. Discussions around spending have come to focus on service provision rather than improving life circumstances. Enhanced service provision alone will not address the growth in inequalities shown opposite.
In addition, approaches to tackling inequalities are being hampered by the ‘evidence-based’ bandwagon, in which all policies and practices need to have been proven before implementation, preferably by randomised control trial. The health impacts of macro-scale social and economic policies cannot, of course, be tested in this way and we feel this weakens the argument for their use. That said, while Gordon Brown remains in command of the Treasury it seems likely that these
three policies will remain in place.
We know that wealth and opportunity foster and promote good health and we have some idea of the benefit if those things can be delivered by appropriate fiscal policy. A crude look at how well these policies are being delivered suggests there has been some progress, but also that there is still a long way to go.
References
The Research Unit in Health, Behaviour and Change is funded by the Chief Scientist Office of The Scottish Executive Health Department (SEHD) and the Health Education Board for Scotland (HEBS). The opinions expressed in this paper are those of the author(s) not of SEHD or HEBS.
The BHPS data used in this article were made available through the ESRC Data Archive. The data were originally collected by the ESRC Research Centre on Micro-social Change at the University of Essex (now incorporated within the Institute for Social and Economic Research). Neither the original collectors of the data nor the archive bear any responsibility for the analyses or interpretations presented here.
Income definition: ‘Equivalised annual net (disposable) household income after housing costs (deflated to August 2000)’. The equivalisation process takes account of household size and composition, where the standard unit for comparison is an adult couple.
Inequalities in life and death: What if Britain were more equal? Richard Mitchell, Daniel Dorling and Mary Shaw The Policy Press, 2000
Price 13.95 (plus 2.74 p&p) Order from: Marston Book Services, Tel 01235 465500
Richard Mitchell is a research fellow and Malcolm McCrae is a PhD student at the research unit in health, behaviour and change, University of Edinburgh; Danny Dorling is professor of geography at the University of Sheffield; and Mary Shaw is scientific director of the south west public health observatory, University of Bristol
