The best way to tackle health inequalities, Mr Cameron, is to tackle all inequality

The reason why the Tory health policy will fail is that you cannot attack major societal inequalities like health inequality without attacking inequality itself

For once, we can agree with the Adam Smith Institute: David Cameron’s new headline plans to “banish health inequalities to history” by introducing “a health premium that targets resources on the poorest areas” will fail.

The key reason why it will fail was already brought out implicitly on Left Foot Forward a couple of months ago – it is that you cannot attack major societal inequalities, such as health inequalities, without attacking inequality itself.

In other words, by far the most consequential way of reducing health inequalities, it turns out, is to target economic and other societally-central inequalities directly. Not to target absolute poverty or ‘deprivation’, not to pursue economic growth, but simply to reduce inequality (whether by reducing high earnings, or by increasing low earnings).

Here is how Richard Wilkinson and Kate Pickett put this point, in their celebrated recent book (pp. 233-4) ‘The Spirit Level: Why more equal societies almost always do better’ (a book given the plaudit by the New Statesman recently of being their “Book of the Decade”):

“For ten years Britain has had a Government committed to narrowing the health gap between rich and poor. In an independent review of policy in different countries, a Dutch expert said Britain was ahead of other countries in implementing policies to reduce health inequalities.

“However, health inequalities in Britain have shown little or no tendency to decline… Rather than reducing inequality itself, the initiatives aimed at tackling health or social problems are nearly always attempts to break the links between socio-economic disadvantage and the problems it produces.

“The unstated hope is that people – particularly the poor – can carry on in the same circumstances, but will somehow no longer succumb to mental illness, teenage pregnancy, educational failure, obesity, or drugs.”

This passage almost reads as if it were written in response to today’s Conservative initiative. If Cameron’s advisers had taken the trouble to read Wilkinson and Pickett, they would have saved themselves from the embarrassment of this new policy of theirs which is fated to fail.

To use a medical metaphor, the ‘health premium’ policy is a band-aid, which will do no good in curing a degenerative condition.

If Cameron were serious about reducing health inequalities, he would target economic inequality directly, as Wilkinson and Pickett recommend. But that would be very hard for the Conservative Party to stomach, seeing as the Conservatives are the party which, under Margaret Thatcher and John Major, pursued policies which hugely escalated inequality, when they were last in power.

In the Preface to their book, Wilkinson and Pickett note that they almost called the book ‘Evidence-based politics’, on analogy with the term ‘evidence-based medicine’.

The subtitle of Left Foot Forward is ‘evidence-based blogging’. The evidence is in – and it shows very clearly that you cannot cure the nation’s health ills, except by curing the nation of the disease of rampant economic inequality.

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16 Responses to “The best way to tackle health inequalities, Mr Cameron, is to tackle all inequality”

  1. Shamik Das

    Why David Cameron’s proposals to abolish health inequalities won’t work:

  2. Rossanna Trudgian

    RT @shamikdas Why David Cameron’s proposals to abolish health inequalities won’t work:

  3. jaqi

    RT @shamikdas: Why David Cameron’s proposals to abolish health inequalities won’t work:

  4. Claire Spencer

    A point made well by @leftfootfwd RT @AndrewSparrow: A Smith Inst attacks Tory health plan …

  5. Matthew Taylor

    It goes without saying – which must be why you didn’t – that Labour’s own policies would at best be no worse than those of the Conservatives.

    Labour trumpeted rebuttals of Cameron’s claim that poverty had increased under Labour, but didn’t pay nearly as much attention to the fact his claim that inequality had also increased was largely born out ( ).

    We’ve had years of Labour setting targets and lovebombing the NHS with money to achieve them. Does it surprise anyone that the debate on healthcare has been twisted into a debate about funding?

    I also can’t see Eamonn Butler taking the view that his message is the same as Wilkinson and Pickett, who want to see a more command based economy, with greater regulation of earnings, to legislate away inequalities.

  6. Lynda Edwards

    I also was totally unimpressed with David Cameron’s speech when I heard it yesterday. He spent his entire speech Labour slamming but didn’t clearly say how he and his cronies would achieve these aims.

    We all know what Tories will do if in power – rich will be richer and poor poorer. Will any jobs for normal workers still be in existence in a few years’ time? I am glad I will be at retirement age later this year – any party realistically being in power will not care about people losing their jobs. More power to the Greens!

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  8. Rupert Read

    Thanks Matthew. I broadly agree with your points; you may [or may not] be aware that I am a Green Councillor. Obviously, Blair and Mandelson in particular were bad for equality; though, to be fair, New Labour have not had nearly as dreadful a record on creating new inequality as the 1979-1997 Tories did.
    One hopes that there are some in Labour indeed who still think of themselves as socialists and thus will embrace the anti-inequality agenda. If so, then better late than never.

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  10. 59782

    I’m all for a bit of equality Rupey. When can I earn the same as you do? And get the same amount of freetime?

  11. Bishop Brennan


    Have you actually examined any of the data around health inequalities? Might I suggest you do so, given your claim to be evidence-based? When you look at the data, what you actually find is that:

    – Differences in life expectancy are greater within groups than between groups, i.e. the differences within Social Class V are bigger than the differences between the different social groups.
    – Even if you were looking at healthy life expectancy, it is impossible to determine causality, i.e. are those who are less healthy poorer because of their ill health or disability (i.e. those with ill health might find it harder to hold down a job), or did their poverty lead to ill-health?

    Essentially, this health inequalities thing is all a load of agenda-driven tosh – arising because people who formerly supported centrally-planned economics (e.g. Michael Marmot) had their dreams shattered when the failures of the Soviet Bloc became all too clear (rather like the Green movement, as it happens…).

  12. Rupert Read

    Mr. Brennan; Your final paragraph here is too silly and rabid to deserve reply.
    As for the question you asked: Yes, I have looked at the data. Have you? If you actually read (for instance) THE SPIRIT LEVEL, you will find that folks such as Wilkinson, Pickett and Marmot have adduced various kinds of strong evidence to support the claim of causality, not merely correlation, between inequality and poor health outcomes.
    By the way, on the question of the failures of the Soviet bloc: Yes, those failures were utterly atrocious, including not least their self-induced environmental catastrophes. But it is to say the least interesting to note the health disaster which has befallen the Soviet bloc since 1989/1991. This disaster strongly supports the view that rising inequality is a major causal factor in poor health outcomes.
    Finally, I don’t understand your first bullet; please clarify. Is the point that different sub-social-groups can have strongly different health outcomes? Well, obviously, and that hardly contradicts the Wilkinson view. Or is the point that health outcomes within ANY social group vary widely? But that only means that some people in a group get ill and others don’t – and that’s true even if you are talking (e.g.) about a group exposed to a dose of radiation or pollution. That’s hardly news!

  13. Bishop Brennan


    Have you actually met and talked to Wilkinson and Marmot? Their version of ‘evidence’ is to assert something, and get angry when you point to analysis that shows that what they are asserting is nonsense. By all means make your claims on LabourList or some other blog, but don’t try to claim this stuff on an ‘evidence-based’ blog!

    And the data does contradict the Wilkinson view: a (very) basic ANOVA analysis shows that there is no correlation (forget causation) between social class and life expectancy. That is, there is no statistical evidence of differences in life expectancy between social classes. So all the claims about health inequalities, let alone the Wilkinson / Marmot view that we need to rack up redistribution to tackle them, are simply based on prejudice.

    The reality is that the causes of poor health are much more complex than suggested by the Wilkinson / Marmot narrative that it’s all about redistributing wealth. Behavioural pyschologists have only scratched at the surface of behaviours that underpin these causes, let alone interventions.

    My guess: to change life chances (which is really what this is all about), we / charities / gov’t / whoever’s best placed need to look at micro-geographies (e.g. sink council estates), understand the cultural and social norms particular to those areas, and focus tailored one-on-one interventions, which cross policy fiefdoms (from health to employment to everything!) on individuals in those areas. The last thing we need is to spend even more tax money on benefits, etc. – these actually seem only to serve to trap people in their circumstances (a tough love approach, with benefits much harder to come by, combined with much higher tax allowances to reward work would be a much better approach).

    But, then, that would end up depriving Labour of its client vote. So you guys won’t be doing it.

    BTW, what evidence can you provide to show that it’s inequalities, rather than other factors, which have led to poor health outcomes in former Soviet bloc countries? I can think of all sorts of reasons for poor health outcomes there – unwillingness to acknowledge an AIDS epidemic, a cultural history of binge drinking, crumbling public services and economy. Why is it inequalities that is the cause?

  14. Rupert Read

    Mr. Brennan;
    you haven’t answered the question in my comment’s final paragraph, above.
    Your comments about Wilkinson et al are virtually entirely ad hominem or unevidenced. I shall wait for your point by point confrontation with the evidence adduced in Wilkinson’s books etc before replying.
    On the Soviet bloc and inequality: yes, the AIDS epidemic is a factor. It explains approx 2-3% of the decline of health outcomes since 1989-1991.
    Crumbling public services of course explain part of the outcome – …but as they are inextricably linked to – partly _coterminous_ with – rising inequality, they are hardly an independent factor.
    Crumbling economy – No, this is no help to you. In Cuba’s crumbling economy, there has not been a massive rise in poor health outcomes? What explains the difference? No rise in inequality in Cuba, that’s what.
    Cultural history of binge drinking – was a factor already before 1989, does not explain the changes observed since then.
    Please read pages 115-122 of Wilkinson’s THE IMPACT OF INEQUALITY. The case is pretty clear cut. The drastic decline in health in the former Soviet bloc is almost certainly very largely caused by the drastic rise in inequality there.

  15. 59782

    Hey Rupey,

    when will I be as equal as you?

    you could have my vote here…

    I do hope those rough, uneductated types from the estate won’t be able to move to my area when they become more equal…

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