Macintyre, S.

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Modernising the NHSPrevention and the reduction of health inequalitiesSally MacintyreThe secretary of state for health recently announcedthe establishment of six “modernisation action teams”to help develop a national plan for a national healthservice.1 The government has committed itself toimproving public health and reducing inequalities inhealth. The decision to set up a “modernisation actionteam” on prevention and inequality is consistent withthese goals. It is not clear, however, what this team isexpected to do that is different from the analysis andrecommendations contained in various recent govern›ment reports.2–7 Saving Lives: Our Healthier Nation saidits aim was “to improve the health of everyone, and thehealth of the worst off in particular.”3 It acknowledgedthe role of social, economic, and environmental factorsin influencing population health and inequalities inhealth but did not confine itself to non›NHS initiativesto improve population health. The Acheson inquirygave careful consideration to recent trends in, possiblecausal models for, and policies to reduce inequalities inhealth and made 39 policy recommendations, three ofthem relating to the NHS.6 So attention has recentlybeen given to the role of the NHS in promoting publichealth and reducing inequalities in health.8 9 What willthis action team do that has not already been donefairly recently? Does the government think that allthese reports were a waste of time or have failed, or thatthe situation has changed radically since they werepublished?Scope of the action teamThe Department of Health has described this team ascovering “prevention—tackling inequalities and focus›ing the health system on its contribution to tackling thecauses of avoidable ill›health.” It also says that all theteams have a remit “to address variations inperformance and standards across the care system as amajor contribution to tackling health inequalities.”Both these statements could be taken to suggest thatthe scope of the prevention and inequality team mightbe confined to the role of the NHS. The prime ministersaid in the House of Commons in relation to thisaction team: “There is the challenge on prevention: tobalance spending on tackling the causes of ill›healthwith treating illness; to develop a more systematicapproach to treating people at risk from chronicdiseases; and to persuade more people to play theirpart in achieving better health by adopting a morehealthy life style.”10 This implies giving priority to thedetection and treatment of people at known andproximate risk of killers such as cancer or heartdisease, and that there will be further attempts tochange individual behaviours by exhortation.It would be disappointing if this action team wasconfined to this sort of agenda. Though the NHS has arole in promoting health, preventing disease, andameliorating the health damage caused by disadvan›tage, most of the major drivers of population healthand of the distribution of health lie outside the NHS.11Health ministers have acknowledged the importanceof air pollution, unemployment, crime and disorder,poor housing, poverty, limited educational achieve›ment, the general environment, and other forms ofsocial exclusion. These influences on health are onlyrarely under the control of the doctors, nurses, or man›agers who are described as being the key architects indrawing up a national plan for a new NHS. Thissuggests that the action team should focus upstreamon the causes of poor health and inequalities in health(what is pushing people into the river), as well as down›stream at the behavioural or other risk factors formajor killers (pulling drowning people out of theriver—for example, by improving the treatment ofmyocardial infarctions in public places).So what should this action team do?Firstly, this action team should review progress onimplementing the public health white papers and theAcheson report. It should establish the extent to whichtheir policy recommendations have been acted on out›side the health departments by other governmentdepartments, local government, and other key actors.Secondly, the team should ensure that some of theextra resources announced for the NHS are directed toworking in partnership with local government andother agencies. Many causes of population ill health,inequalities in health, and lack of uptake of healthylifestyles lie not in individuals but in the social andphysical environment. Rather than focusing exclusivelyon “at›risk people,” the government and healthcaresystem should also focus on the role of opportunitystructures in local environments—for example, on theSummary pointsThe major drivers of health and the distributionof health lie outside the health service, so thisplan should not confine itself to actions that couldbe taken by the NHSThe government should review progress inimplementing the Acheson report on inequalitiesand the public health white paperSome of the extra resources should be spentin partnership with organisations outside the NHSThe government should acknowledge the tensionthat exists between overall health gain andreducing inequalitiesThe priorities of the Acheson report should beacted onEducation and debateThis is thesecond of sevenarticlesMRC Social andPublic HealthSciences Unit,University ofGlasgow, GlasgowG12 8RZSally Macintyredirectorsally@msoc.mrc.gla.ac.ukBMJ 2000;320:1399–4001399BMJ VOLUME 320 20 MAY 2000 bmj.comavailability of safe play spaces for children, accessibleand reasonably priced food, educational and employ›ment opportunities, and housing built and maintainedto tolerable standards.Thirdly, it should develop a strategy for dealing withthe tension between the goals of generating overallhealth gain and the reduction of inequalities. Thisinvolves recognising that both poor and rich people areliving longer, but the healthy life expectancy of richpeople is increasing faster than that of poor people.Health promotion strategies focusing on individualhealth behaviours such as smoking, diet, and exerciseare more commonly and quickly taken up by those withbetter personal and local resources. Thus althoughthere has been an overall reduction in the prevalence ofsmoking in Britain, there has been a widening gapbetween social classes in the prevalence of smoking andsmoking related diseases. The health gain to beobtained from any given input depends on the capacityof the target population group to benefit. The capacityto benefit from individualised risk management orhealth education may be least among more disadvan›taged people, and therefore the costs (to them andothers) of improving their health may be greater thanthe costs of improving the health of relativelyadvantaged people. The action team needs to deal withthis problem explicitly.Fourthly, the team should take forward the threeareas given highest priority by the Acheson report6:x “All policies likely to have an impact on healthshould be evaluated in terms of their impact on healthinequalities.” The team needs to establish appropriateways of measuring and monitoring the impact onhealth inequalities of activities in a range of sectors(transport, housing, education, taxation, and thebenefits system, as well as the healthcare system).Evidence based medicine is now well established in thiscountry, but evidence based policymaking is not. It isimportant that robust methods are developed forevaluating the impact of policies, programmes, andprojects on the health of the population and of differ›ent subgroups, since such activities might damagehealth rather than promote health and may havedifferent effects on different groups. Impact on healthis not the same as impact on health inequalities; someinterventions might generate an overall health benefitbut may either increase social inequalities in health ordamage the health of some population groups, and weshould be monitoring this.x “A high priority should be given to the health offamilies with children.” Most of the recent analyses ofdeterminants of population health, and of inequalitiesin health, show the likely importance of early life influ›ences on health and the lifetime cumulative effect ofexperiences and exposures. Focusing on families withchildren will not only help with immediate problems ofmaternal and child health but may help reduce thelonger term risks of adult chronic illnesses such asbronchitis and coronary heart disease.x “Further steps should be taken to reduce incomeinequalities and improve living standards of poorhouseholds.” Inequalities in health are ultimatelycaused by social inequalities (in income, wealth, educa›tion, and other life chances). If we seriously want to tryto reduce inequalities in health we should try to reducethe structured social inequalities which create them,rather than focusing on the immediate short term risksthat are manifestations of an unequal society (such asobesity, high cholesterol, poor lung function conse›quent on many years’ smoking, or early and unplannedpregnancy).Competing interests: None declared.1 Enthoven AC. A promising start, but fundamental reform is needed. BMJ2000;320:1329›31.2 Department of Health. Our healthier nation: a contract for health. London:Stationery Office, 1998.3 Department of Health. Saving lives: our healthier nation. London: Station›ery Office, 1999.4 Scottish Office Department of Health. Working together for a healthier Scot›land: a consultation document. Edinburgh: Stationery Office, 1998.5 Scottish Office Department of Health. Towards a healthier Scotland: a whitepaper on health. Edinburgh: Stationery Office, 1999.6 Acheson D. Independent inquiry into inequalities in health: report. London:Stationery Office, 1998.7 Department of Health. Reducing health inequalities: an action report.London: Department of Health, 1999.8 NHS Centre for Reviews and Dissemination. Review of the research on theeffectiveness of health service interventions to reduce inequalities in health. York:NHS Centre for Reviews and Dissemination, 1995.9 Department of Health. Variations in health:what can the department of healthand the National Health Service do? London: Department of Health, 1995.10 Blair T. NHS modernisation. House of Commons official report (Hansard)2000 March 22:cols 981›4. www.publications.parliament.uk/pa/cm199900/cmhansrd/cm000322/debtext/00322›04.htm#00322›04_spmin0 (accessed 27 April 2000).11 Shaw M, Dorling D, Gordon D, Davey Smith G. The widening gap. Healthinequalities and policy in Britain. Bristol: Policy Press, 1999.JEZCOULSON/INSIGHTWhat should the action team do?Review progress on public health reportsEnsure that extra resources go towards working inpartnership with local government and other agenciesDevelop strategy for dealing with tension betweenoverall health gain and reduction of inequalitiesTake forward the areas of highest priority given in theAcheson reportEducation and debate1400 BMJ VOLUME 320 20 MAY 2000 bmj.com

Modernising the NHS: prevention and the reduction of health inequalities

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