The new chief executive of the UK Public Health Association, John Nicholson, sets out his stall for EHJ

When Tony Blair toured the north of England to expose the wide variations within regions as well as between them, and when Alan Milburn declared commitment to tackling inequalities in heart disease as part of making a fairer society generally, then something had obviously struck a chord. It is rare for any academic work to have such an effect on the media and ministers, but the evidence of The Widening Gap in late 1999, and its headlined Mrs Gaskell-like north-south divide, was impressive and lasting.(1) Politically, the heartlands needed renewed attention.

It is in the wake of this that the budget has awarded billions to the NHS, in return for which the NHS is to be modernised (further still). And in doing so the importance of tackling inequalities is recognised sufficiently, that one of the six key modernisation action teams (MATs) is on prevention and inequalities. This team is devoted to outlining the health system's contribution to tackling inequalities.

The important hidden message here is that while the plan is to improve the NHS, it is understood that the NHS alone is not responsible for all health inequalities. In other words, as the NHS is looked at to provide a "contribution", then there must be other agencies and factors which also have an impact. Health is not the concern of the NHS alone. The involvement in the modernisation action teams of local government and the voluntary sector is a move in the right direction. And there has also been the emergence of a national strategy for neighbourhood renewal, which aims to bridge the gap between the poorest neighbourhoods and the rest of the country. The strategy plans to take action in all the poorest neighbourhoods, leading to lower long-term unemployment, a reduction in crime and hopefully higher standards of health and better qualifications. Additionally the two core themes are reducing inequality and ensuring improvement in living standards in deprived areas.

It is not only the gap between rich and poor which must be overcome, but also the discrepancies between health services and other departments, nationally and locally, which all too often hamper a successful implementation of the initiatives that could be most effective. Not only must health and local authorities work together in local planning and delivery, but government departments must take a lead nationally, and promote joint-working practice at local level.

The UKPHA
The UK Public Health Association brings people together to promote the health of the public and to advocate for healthy public policy. We seek to overcome both the gaps in process and practice. We are committed to tackling health inequalities and to sustaining the environment. And we are committed to doing this by involving health and local government, together with community and voluntary organisations, so that the experiences of people at local level are communicated to the decision-makers nationally, across the UK and its new governing arrangements.

This is why we are raising the call for overall targets to tackle inequalities across the board, and for the Government to find effective ways to develop and monitor such targets. It was particularly rewarding to see contributions to our recent conference from both the Minister for Public Health, Yvette Cooper, and the Under-Secretary for the Environment, Lord Larry Whitty, and to hear both reflect on the importance of the other's department. As Lord Whitty pointed out, he is responsible in the Lords for answering questions on just about everything, and since just about everything impacts on health, then it is only right that the link between environment and health should be recognised.

It is also positive to see such interest in joint-working practices between the Local Government Association in England and the UKPHA. Our recent joint conference on the role of local government in health, and our joint response to the English white paper, Saving Lives: Our Healthier Nation, are practical examples where work can be taken forward. We look forward to similar developments across the UK as a whole. Our growing membership of local government officers, active in environmental health, is helping to develop our links with the new regional bodies too (we are not an organisation claiming to be "national" as we only operate in London!).

Forging the Links
It is also refreshing to find that some of the arguments about the wider determinants of health are now more widely accepted. For example, the link between health and housing: "Being healthy is often a hidden prerequisite for being able to live in the areas where people have the best health; you have to be well enough to be in work to pay the mortgage required to have a home there."
The mortality rate of men living in privately rented accommodation was 38 per cent higher in 1995 than for owner occupiers - for council tenants it was 62 per cent higher. Five of the constituencies with the highest mortality rates in the 1990s experienced the largest decline in population 20 years earlier (which particularly affected cities such as Glasgow, Manchester and Liverpool). The people left behind were some of the most deprived in Britain.(3)

As home ownership has risen nationally, so has homelessness. For the factors that affect health affect where you can choose to live - this operates across space (through migration) and time (through the advantages rich children gain from growing up in rich areas and the disadvantages poor children suffer in poor areas). It also operates across the different areas of the UK, across Europe, and the world. So there is a lifetime effect, not based on any one static social circumstance. It is an accumulation. Educational attainment is related to health through the advantages it gives people in their socio-economic status, not simply because education encourages health conscious behaviour.

Health-related behaviour, such as smoking and diet, are strongly influenced by social environment. Whether you look at education, social class, housing tenure or car ownership, those who are more advantaged have better relative life chances. They are coincident geographically and cumulative socially. Health inequalities are produced by the clustering of disadvantage - in opportunity, material circumstances and behaviour related to health - across people's lives. The polarisation of life chances this creates highlights the need to address the problem at its roots.

Structural Change
But as the argument seems won, there is a parallel danger that the Government desire to "join up" all departments, positively to emphasise the importance of all their activities, has in practice already been undermined.(5) As the seesaw tilts, the argument is that the NHS has for too long neglected health, so it should give it proper attention. "Health" may once again become the property of the NHS.

And decision-making is still delegated to the lowest level. It is up to local health authorities to seek partnership and consensus at local level; even though there are actions crying out to be taken at a more strategic, perhaps regional, level. Local government may have "permission" to be involved in health, but does not have the requirement (or resources) to do so (in terms of local decision-making structures). Nor does it have the lead which its local democratic mandate could demand. The health improvement programme belongs to the health authority. Council involvement in health is often limited to social services departments. But real joint-planning requires one joint plan (the community plan?), connected to all departments.

So on the one hand there is devolution (to parliaments and assemblies). On the other hand there is fragmentation (to primary care groups and their equivalents). The health of the public may be secondary to the latest (re-) organisational requirements of the NHS. Crucial to this, is the question of effective and measurable targets on tackling health inequalities - which need to be effected and measured. Despite the UK being a signatory to WHO's Health 21, the Government has been unwilling to adopt the relatively unambitious target to reduce the health gap by at least one quarter by 2020. The idea seems to be that health is dependent on economic growth and that the public isn't prepared to vote to end poverty and ill health, if it means raising taxes.

Health Odyssey 2001
Maybe we need a Health Odyssey 2001 - to rediscover the Black Report from 20 years ago.(6) For the truth is that the root cause of inequalities in health is still poverty; that significant advances could be made across the UK with under 2 per cent of GDP; and that the Government's top priority must be to reverse the process of widening income inequality. Piecemeal solutions - the crumbs and circuses of zones and domes - are unlikely to be structurally effective.

We need, as a society, to mind the gap - to mind that there is a gap. We need to say health - for all - matters. And to do so we need to say that income redistribution matters. While the media were right to highlight the north-south divide, it must be more lasting than a soundbite.
For with the continued existence of poverty and inequality, those living in less advantaged social circumstances get the worse end of the deal, whatever the actual diseases and set of exposures which mediate social disadvantage and disease. Tony Blair can say that he is "abolishing" the north-south divide. But this is no substitute for action to tackle the structural divide which makes us all, individually and as a society, unequal and poorer as a result.

Rather than maintaining a divide (and rule?) this Government must be tough on inequalities in health and tough on the causes of inequalities in health.

References
1. The Widening Gap: Health Inequalities and Policy in Britain, Mary Shaw, Daniel Dorling, David Gordon, George Davey Smith; University of Bristol, November 1999
2. National Strategy for Neighbourhood Renewal: a framework for consultation, a report by the Social Exclusion Unit April 2000
3. The Widening Gap
4. The Economist December, 1999
5. Frank Dobson in 1998 stressed "our commitment to reducing these massive inequalities in health isn't just a matter for the Department of Health. If it's to work, the whole of Government must play its part. And it is. The Prime Minister is passionate about reducing these inequalities". Citing food improvement and tackling traffic pollution, he then went further: "It's not just a job for central government and the NHS. It's a job for local councils, voluntary organisations and businesses in every locality." And Tessa Jowell set out "a third way between the old extremes of individual victim blaming and nanny state social engineering.. it is a national contract for better health .. government, local communities and individuals will join in partnership to improve all our health".
6. Inequalities in Health: Report of a Working Group, DHSS, London, 1980 (Black Report)