Godivaville – a (fictional) socially and economically disadvantaged town – has higher rates of death and illness than most of the West Midlands, largely due to the poor health of particular groups. The town has a largely ‘young’ population, many lone-parent households, very high unemployment, and a relatively large proportion of ethnic minorities. Several health inequalities are evident, the most obvious being between social classes; mirroring national figures, the life-expectancy for social class one exceeds by more than nine years that for class five (Hattersley, 1999), and morbidity data shows a similar pattern. There are also health inequalities between genders – females having lower mortality but higher morbidity rates – and between ethnic groups. This report offers likely explanations for these relationships, then suggests how health inequalities might be tackled.
The Health Inequalities in Godivaville and their Possible Explanations
The Black Report (DHSS, 1980) gives four main explanations for health inequalities between classes: explanations based on artefact, on social class, behavioural/cultural explanations, and material explanations.
As regards the first, the report cites various inherent problems with classification schemes such as the Registrar General’s classification. It is, for example, possible for people to assign themselves a higher social class than the one assigned them at their death; we may then be led to associate high mortality with low social class. However, the OPCS Longitudinal Study and various other researches have shown it unlikely that artefactual bias has any part to play (Blane, 1999).
Social selection has been shown to occur, and could contribute to health inequality between classes. If so, its being only properly applicable to the first half of life – when people are less likely to be ill – makes it negligible. Were it significant, we would expect to see steeper gradients for chronic diseases than acute diseases, but we do not (Blane, 1999).
Behavioural/cultural explanations suggest that poorer health in classes IV and V is a consequence of less healthy behaviour (Busfield, 2000). There are a number of problems with applying this explanation alone (Benzeval et al 1996). In Godivaville, though behaviour associated with poor health is more prevalent among the lower classes – smoking, for example, and lower consumption of fresh fruit and vegetables – it is impossible to isolate this behaviour from the material environment in which it occurs; it may result directly from factors such as the lack of money to buy fresh fruit and vegetables, or be mediated through psychological factors such as stress and monotony, which encourage behaviours like smoking. In addition, evidence from intervention studies have often improved health behaviour without achieving a corresponding improvement of health (Blane, 1999).
Material explanations are judged by the Black Report as the most important. The houses of poorer people are less likely to be their own and more likely to be badly constructed, damp, and overcrowded (Blane, 1999). Lack of choice in accommodation can lead to loss of social support: financial and material support, as well as friendship. Occupational hazards such as exposure to toxic substances are more common among manual workers. The material needs of the unemployed and those in low-income families, if met, are often only done so at the expense of social needs (Blackburn, 1999). Material environment, as mentioned, bears strongly on psychological well-being, and on health behaviour; there is under-utilization of services (Shaw et al, 2000), probably due to inequalities in resource allocation, practitioner attitudes and perceptions, and material and social barriers such as access to transport (Blackburn, 1999).
Another factor besides these four that must be brought into the picture is Wilkinson’s theory of social cohesion (Busfield, 2000). As with behavioural/cultural factors, the concept of social cohesion is entwined with material circumstance, and its importance is therefore difficult to determine.
Besides the health inequalities between classes, we must reckon with those between genders and ethnic groups. Women in Godivaville – as in Britain as a whole – have a longer life expectancy than men but higher rates of morbidity. The explanation of male biological vulnerability ignores social factors such as the gender division of labour at work and at home, and mens’ attitudes to reporting illness.
As regards ethnic groups, some authors say that the poorer health of minorities rests on class/income inequalities (Navarro, 1990), though others say the explanation is more complex (Davey et al, 2000). In addition to the barriers associated with socio-economic disadvantage, such minorities often also experience those associated with language, racism, and stereotypical views of health professionals.
Narrowing the Health Inequalities in Godivaville
The Health Inequalities Report, commissioned by the government in 1997, highlighted the need to intervene on a broad front, with ‘upstream interventions’ to tackle the root causes of poverty. Local measures alone are insufficient; the way must be paved by national government policies.
In national policy, social class inequalities are the main area for intervention, as they go a long way to explaining other inequalities. Effective polices address the root causes of poverty, focusing on improvement of material circumstances rather than behaviour. This can be done by raising incomes in cash or in kind.
The government has introduced the Welfare to Work scheme to improve incomes in cash by reducing unemployment. Such schemes, however, can only be successful in areas where jobs are available. (How to create more jobs in Godivaville will be addressed in the next section). Economists have suggested a number of basic income schemes that could effectively end poverty in Britain (Shaw et al, 2000). This would be intervention in the broadest sense, filling the poverty gaps left by current benefits.
Specific areas for intervention include child poverty, which can have an impact throughout the life-course. This can be addressed through, for example, increased maternity allowance for women on income support or in low paid jobs, and increased benefits for lone parents. Many disabled people – 45% is estimated (Berthoud et al, 1993) – are living in poverty. Disability benefits are often too low to meet basic needs (Gordon and Heslop, 1999) and must be increased to meet needs that come with disability and ill health. The elderly are more likely to have poor health, a situation exacerbated by poverty. This is best addressed through pensions policy, with a reduction in means testing, and tighter regulation to prevent misleading selling of personal pensions (Shaw et al, 2000).
The importance of incomes in kind should not be overlooked. At a national level the NHS could improve targeting through regular equity audits that identify the areas in greatest need, allowing a redirection of services. (How to improve the effectiveness of in kind services will be discussed further with regard to local schemes.)
In Godivaville – as in the UK as a whole (Shore et al, 2000) – an ‘inverse care’ law seems to operate, where disproportionately more resources are used by ‘richer’ households than ‘poorer’ households. There is the potential for Godvaville’s Primary Care Group (PCG), which brings together General Practitioners, nurses, pharmacists, social services and health authority representatives, to respond to the specific needs of the town’s population. Health profiles are important in guiding the targeting and prioritisation of resources. Health service accessibility might be improved by the provision of transport to those in need, more flexible opening hours of GP surgeries, and a greater emphasis on outreach services.
Education schemes, geared to the population’s needs, can help reduce unemployment, but this is limited by the number of jobs available. Industry must therefore be encouraged into Godivaville by regeneration, seeking out new trade opportunities, and by promoting the city as a centre for investment. The barriers to employment for certain groups must be addressed; we must deal with all discrimination, campaign for unemployment data to include ethnic origin, and provide affordable childcare and other facilities.
Godivaville is a clear candidate for a program such as Sure Start. Such a scheme should combine resources to determine particular needs and ideally, the catchment area should not be too limiting. Many families with small children live in high-rise buildings. Improving their current accommodation is essential, key issues including safety and recreation, such as the provision of enclosed play areas.
Barriers to health for minority ethnic groups – such as language and attitudes of health practitioners – need addressing (Coventry’s Community Care Plan, 1997). The accessibility of domestic violence services needs particular attention; the uptake of such services by Black women in Godivaville is far lower than by other ethnic groups. Stereotypical attitudes towards black women and domestic violence need challenging.
Health practitioners have a part in reducing health inequalities (Blackburn et al, 1999). There should be an overt poverty perspective incorporated in health practice education, which includes the challenging of negative attitudes towards poverty. Practitioners also have an important role in lobbying for changes in the way services are delivered.
Other suggestions for action in Godivaville include the introduction of food co-operatives, efficiently targeted information on dental care, and increased support for carers.
The health inequalities in Godivaville are complex, but have most of their roots in inequalities in material wealth. They can only therefore be successfully tackled by reducing poverty through Government national policy. Local intervention, with a united community, can then effectively consolidate these policies.