Inequalities in health: what health systems can and cannot do

Author(s): Peggy Foster

Source: Journal of Health Services Research & Policy , July 1996, Vol. 1, No. 3 (July
1996), pp. 179-182
Published by: Sage Publications, Ltd.

Stable URL: https://www.jstor.org/stable/26750296

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide
range of content in a trusted digital archive. We use information technology and tools to increase productivity and
facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
https://about.jstor.org/terms

Sage Publications, Ltd. is collaborating with JSTOR to digitize, preserve and extend access to
Journal of Health Services Research & Policy

This content downloaded from

152.118.24.31 on Tue, 28 Sep 2021 04:55:22 UTC
All use subject to https://about.jstor.org/terms
 -? t-i- r^~

Inequalities in health: what health systems can

and cannot do

Peggy Foster
Department oi social roncy ana 5ociaJ worK, ine university oi Manchester, uk

Health promotion activities are actively encouraged in most countries, including the UK Meanwhile many health care
providers and health experts are becoming increasingly concerned about the growing evidence of significant health
inequalities between social groups in the UK, and in particular the strong association between relative deprivation
and poor health. In 1995, a report for the British government entitled 'Variations in health: what can the Department
of Health and the NHS do?', identified the need for the Department of Health and the NHS to play a key role
in coordinating and implementing public health programmes intended to reduce inequalities in health. Examination
of existing evidence on the effectiveness of health promotion and prevention programmes designed to improve
the health status of the most vulnerable groups in society reveals very little evidence to support current enthusiasm
for adopting public health strategies in order to reduce variations in health status between the affluent and the
poor. Alternative and potentially more effective health care responses to inequalities in health status need to be
considered.

Journal of Health Services Research and Policy Vol. 1 No. 3,1996:179-182 © Pearson Professional Ltd 1996

Introduction report concluded that 'the weight of evidence continues

to point to explanations which suggest that socio
In October 1995, a working group in the UK published
economic circumstances play the major part in subse
a report entitled 'Variations in health: what can the
quent health differences', and that 'certain living and
Department of Health and the NHS do?'1 The group
working conditions appear to impose severe restrictions
concluded that the main explanation for observed
on an individual's ability to choose a healthy lifestyle'.2
differences in health and life expectancy between social
In 1993, participants at a seminar that focused on possi
groups was 'the cumulative differential exposure to health
ble policies to reduce inequalities in health, reinforced
damaging or health promoting physical and social envi
the growing consensus that a reduction in poverty would
ronments.' They also stated that 'it is probably the case
be an essential part of any strategy to reduce inequalities
that access to health services plays a much greater part
in health. A summary of their discussions stated, 'A
in ameliorating the effects of health variations than in
worthwhile agenda for tackling inequalities in health
preventing or reducing them'. In other words, access to
must... include a strong focus on reducing poverty.. ,'s
health services does not play a significant role in prevent
Yet, despite this growing consensus that economic in
ing variations in health status.
These conclusions are not new. Social scientists re equality creates health inequalities, the UK government
and many health experts continue to propose elaborate
searching variations in health status have been stressing
public health schemes for tackling inequalities in health,
the importance of socio-economic inequalities as a key
including the Variations in Health working group. If we
determinant of inequalities in health status for well over
examine their recommendations more closely, we find
a decade. In 1980, a report for the Department of Health
that many of their recommendations involved a signifi
concluded that 'while the health service can play a sig
nificant part in reducing inequalities in health, measures increase in resources for public health programmes.
cant
For example, the group complained that all too fre
to reduce differences in material standards of living at
quently public health programmes to date had been
work, in the home and in everyday social and commu
'time limited, funded from non-recurring sources and
nity life are of even greater importance. We have in mind
marginal to mainstream health authority activity'. It then
not simply a general reduction of inequalities in living
went on to advocate the allocation of 'mainstream re
standards, but a marked improvement in the living
sources' to public health programmes, albeit with the
standards of the poorest people'.8 In 1987, a follow-up
very strong proviso that these programmes must be care
fully costed and then evaluated rigorously to determine
their cost-effectiveness. But on what existing evidence of
Peggy Foster, Lecturer in Social Policy, Department of Social Policy
and Social Work, The University of Manchester, Manchester, UK. the effectiveness of such programmes did the working
group base its recommendations?

J Health Serv Res Policy Volume 1 Number 3 July 1996 179

This content downloaded from

152.118.24.31 on Tue, 28 Sep 2021 04:55:22 UTC
All use subject to https://about.jstor.org/terms
Perspective Inequalities in health: what health systems can and cannot do

What evidence is there that public health or an improvement in health knowledge. Virtually no
interventions reduce inequalities in evidence was provided of an improvement in health
health? status itself. For example, Marsh and Channing8 did not
provide any evidence that the health status of their
There appears to be remarkably little evidence ofdeprived
any patients had improved as a result of their in
significant positive impact of health care interventions
creased use of preventive services. Similarly, the study
intended to improve the health status of the most vulner
which achieved a small improvement in Asian women's
able groups in our society. A recent review of the re
uptake of cervical smear testing noted without comment
search evidence identified 94 studies which satisfied all that all the smear test results for the women who came
the review inclusion criteria. Their report was based onforward for testing were normal.6 This can only mean
these. It concluded - with some regret - 'that the evi that this intensive health promotion drive did not in any
dence to date on practical public health interventions way improve the health status of the particular women
in which the NHS might engage to reduce variation intargeted, since they were not suffering from any of the
health is, at best, scant'.4 Some 'successful' interventionscervical abnormalities which the smear test is intended
were identified, though a closer examination of some to pick up.
of these interventions reveals the problematic nature of Members of the review team concluded that 'Health
much of that 'success'. Three key weaknesses in these care professionals have been rightly criticised for assum
successful studies can be readily detected. ing that what they do is effective, and evaluation has
First, the changes achieved were usually small. For shown some cherished treatments to be of little use. It is
example, a study by McAvoy and Raza,5 which aimed toequally important that strategies developed to reduce in
increase attendance for cervical smear testing among equalities are not assumed to be having a positive impact
Asian women who received a home visit and a video on simply because the aim is "progressive" and so rigorous
cervical screening in their own language, only achievedevaluations of promising interventions are important'.9
an attendance rate of 30% in the group offered a In fact, there is already a large body of evidence which
visit.
Although this figure was much higher than the 5% at
challenges the optimistic assumptions made in many of
tendance rate in the control group, it does not comparethe 94 studies reviewed that either an increased uptake
very favourably with the national average take-up rateof ofa preventive service or an increased knowledge of
over 80%.6 Another 'successful' intervention by James healthy behaviours will improve the health status of de
et al,7 which was based on a programme of dietary prived
educa groups.
tion given to a selected group of young mothers living inFive of the intervention studies reviewed had at
a deprived inner city area in Britain, managed to raise
tempted to tackle inequalities in relation to the risk of
the mean score of the children's dietary content fromsuffering from heart disease by altering adults' diets. Yet
5.3 to 7.6 (maximum score 12). The authors concluded according to a number of experts it is virtually impossi
that 'It was encouraging to find that the improvementble
in to prevent heart disease through altering the dietary
the dietary scores following the intervention was behaviours
sup of free-living subjects. For example, in 1991
a review article by Ramsay et al10 examined the results of
ported by the mothers' perception of this improvement,
without the introduction of additional finance'. However,
16 trials designed to use dietary changes to lower serum
the reviewers of this study commented, 'The impact cholesterol
of concentrations in mainly middle-aged men.
this intervention was small despite its intensity'.4 The authors of this review article claimed that the results
Second, the small changes reported in the studies
from these trials strongly suggested that, although the
deemed by the review team to have been successful type
were of dietary changes now being advocated by health
only achieved by intensive interventions which werepromotion specialists might well be acceptable and were
'probably perfectly safe', they were simply not effective
uncosted. For example, the study by James et al,7 which
because the reduction in fat intake was not severe
improved the dietary scores of the children of young
enough to produce any useful fall in a subject's choles
mothers living in deprivation, involved intensive home
terol
visiting by health visitors. On average, each mother re level. Very rigorous diets had been shown to reduc
cholesterol concentrations 'substantially' but such diets
ceived between 8-9 hours of one-to-one teaching about
healthy eating. Yet the cost of this programme waswere not 'unpleasant'. They concluded that, whilst relatively
calculated. Similarly, a study by Marsh and Channing,8 painless dietary changes, such as a small reduction in th
proportion of fat in an individual's diet, might be harm
which reported a significant increase in uptake of a range
lessinin themselves, the official promotion of such dietary
of preventive services provided by a general practice
changes could be considered harmful on the ground
north-east England, documented that the intensive effort
that
involved in achieving this increase had included a lot of scarce resources were being wasted on useless types
of intervention.
extra clerical work and some home visits by doctors
specifically to carry out preventive interventions. HowThree of the 94 studies reviewed had attempted to
ever, whilst the authors of this study acknowledgedimprove
the ethnic minority women's uptake of breast can
cer screening,
cost implications of such intensive effort, they provided two successfully and one unsuccessfully.
no costing for their own study. The reviewers commented on the successful study by
Third, most of the success documented was limitedZavertnik
to et al,11 'This study presents reasonable evidence
that an intensive community intervention can improve
an increase in the uptake of preventive health services,

180 J Health Serv Res Policy Volume 1 Number 3 July 1996

This content downloaded from

152.118.24.31 on Tue, 28 Sep 2021 04:55:22 UTC
All use subject to https://about.jstor.org/terms
Inequalities in health: what health systems can and cannot do Perspective

uptake of breast screening and reduce the proportion of sources from the middle classes to the poor. The UK
breast cancers diagnosed at late stages'.4 However, critics government continues to back the medical consensus on
of breast cancer screening programmes have pointed the need for an expansion of public health programmes
out that earlier diagnosis of breast cancer should not be and has strongly supported moves within the NHS to
equated with the discovery of a curable disease.12 Until give a much greater priority to clinical prevention and
breast cancer specialists can guarantee a cure for very health promotion programmes. However, health policy
early breast cancers, the effectiveness of mass screening makers may wish to ask themselves what they will be
remains highly questionable. Some experts have also creating when they devote more resources to public
emphasized the very high economic cost of mass breast health programmes based very firmly on a medical
cancer screening programmes. According to Wright and model of health promotion. It might turn out to be a
Mueller, for example,'If a mean figure of population variant of the Emperor's new clothes.
benefit is accepted from the randomised clinical trials
around 20 000 women would have to be screened for
What should be done?
1 to benefit. At a low overall cost of US$60.00 (£28) per
mammogram, the cost of each woman benefited is US$1.2 In the 1970s many critics of the NHS accused it of be
a
million (£558 000)'.13 Any full cost-benefit analysis ofsickness rather than a health service, and called for fa
mass screening programmes must also take account more of resources to be devoted to preventive health care.1
the well-documented psychological and physical harm In retrospect, this demand may have been misguide
Good health is the product of a very complex range
imposed on individuals who receive a false positive test
factors, most of which are, unfortunately for health ca
result. This includes the trauma of receiving a temporary
diagnosis of breast cancer and the increased likelihood
providers, completely outside their control. Yet par
of undergoing further, more invasive, investigations.14,15 for political reasons, and partly as a consequence of t
view that modern medicine would be effective if on
Finally, it is important to note that several of the studies
it intervened earlier and more often in individuals' liv
in the review were unsuccessful, even according to their
own limited evaluative criteria. For example, a studyhealth
by promotion activities are currently absorbing e
increasing
Hoare et al,16 evaluating the impact of home visits by a amounts of scarce health care resourc
linkworker who personally invited Asian women for Given the inevitability of limitations on overall heal
breast cancer screening, found no overall difference care
in resources, maybe the time has come for hea
attendance rates between the targeted group and the policy-makers to take a stand against a medical cons
control group. Another outreach programme which pro sus which proposes ever-increasing costly interventi
vided an educational video on the dangers of smoking in the lives of healthy individuals. It may well be po
during pregnancy to pregnant women living in inner cally impossible within the foreseeable future for pol
city areas in the USA did not produce a reductionmakersin to consider a redistribution of resources aw
smoking that was statistically significant.17 from public health programmes and towards direct
come redistribution to the poor. It may be more feasible
however, for those managing health care services to
The policy response to the evidence
sider switching resources from public health programme
of unproven effectiveness to acute services of prov
If all the evidence strongly suggests that further attempts
to reduce inequalities in health through public health
effectiveness which are at present distributed in w
programmes are likely to prove ineffective whilst absorb
which disadvantage those groups already suffering fr
ing significant amounts of health care resources, we may
the worst health in our society.
well ask why any government would continue to support For example, working class women who are diagnos
activity in this area of health care? One answer is that
as suffering from breast cancer die sooner than mid
those given the task of creating strategies to reduce
class women, and some health care experts have s
inequalities in health are predominantly health care
gested that this inequality is at least partly the result
specialists. For example the 'Variations in Health' report
middle class women receiving better quality treatme
was produced by 13 members, comprising three public rather than earlier detection. Breast cancer specialis
health doctors, a nurse manager, a professor of general have claimed that if all breast cancer patients were treat
practice and a senior medical civil servant. It is hardlyin specialist centres more women would live longer.19
true, this would use extra health care resources, but
surprising, therefore, that this group gave health services
a key role in tackling inequalities in health status despite
can at least hypothesize that such a development mig
their acknowledgement that the primary causes of in do more to reduce inequalities in health than labo
equalities lay outwith health care. Another reason why intensive, and therefore costly, attempts to persuad
expenditure on health care continues to rise at a time women from deprived areas to accept mammograph
when expenditure on other welfare services suchscreening as of unproven effectiveness. It has also bee
housing and social security is being cut back or rigidly claimed that ensuring better access to coronary arte
controlled is that health care is particularly popular withsurgery for people with coronary heart disease in d
the public. Politicians know that health care initiatives prived areas may help to reduce inequalities in de
such as national screening programmes are far more
rates.9 Again this policy might well prove more effectiv
politically popular than any attempts to redistributein
re tackling inequalities in health amongst middle-ag

J Health Serv Res Policy Volume 1 Number 3 July 1996 1

This content downloaded from

152.118.24.31 on Tue, 28 Sep 2021 04:55:22 UTC
All use subject to https://about.jstor.org/terms
Perspective Inequalities in health: what health systems can and cannot do

men than intensive health education programmesinequalities

which in health: an agenda for action. London:
King's of
attempt to change, against all the odds, the behaviour Fund, 1995
4. NHS Centre for Reviews and Dissemination. Review of the
those living in poverty. research on the effectiveness of health service
Inequalities in access to acute health services can
interventions to reduce variations in health: CRD Report
affect not just mortality rates but also the quality of The University of York, 1995
3. York:
5. McAvoy B R, Raza R. Can health education increase
individuals' lives. John Yates50 has recently highlighted
uptake
the inequality in waiting times for routine but of cervical smear testing among Asian women?
life
British Medical Journal 1991; 302: 333-336
enhancing operations, such as cataract surgery and hip
6. NHS Cervical Screening Programme National Co
replacements, which exist between patients who can Committee. Report of the first five years of the
ordinating
afford private health care and those who cannot.NHSYates
cervical screening programme. Oxford: NHSCSP,
1994
claims that 'we are now returning to a health care system
7. Jamesto
beset by the very inequality the NHS was designed J, Brown J, Douglas M, Cox J, Stocker S. Improving
the diet of under five's in a deprived inner city practice.
remove.' Lack of resources is not the only cause Health
of long Trends 1992; 24:161-164
waiting lists for certain types of operations, but under
8. Marsh G N, Channing D M. Narrowing the health gap
funding is undoubtedly part of a 'lethal cocktail'between
which a deprived and an endowed community. British
Medical
creates long and extremely inequitable waiting times forJournal 1988; 296:173-176
9. Arblaster L, Lambert M, Entwistle V et al. A systematic
surgery. Any meaningful attempt to create more equal
review of the effectiveness of health service interventions
access to acute health care will therefore involve extra
aimed at reducing inequalities in health. Journal of
expenditure, but there is at least some evidence to suggestHealth Services Research and Policy 1996; 1: 93-103
that this expenditure, if very carefully targeted, could
10. Ramsay L, Yeo W, Jackson P. Dietary reduction of serum
produce real health gains amongst deprived groups. cholesterol concentration: time to think again. British
Medical Journal 1991; 303: 953-957
11. ZavertnikJJ, McCoy C B, Love N. Breast cancer control
Conclusion program for the socio-economically disadvantaged.
Screening mammography for the poor. Cancer 1994;
Policies designed to equalize access to acute health
74(suppl): 2042-2045
services would clearly do nothing to tackle the 12. Skrabanek P, McCormick J. Follies and fallacies in
under
medicine. Glasgow: The Tarragon Press, 1989
lying causes of inequalities in health status. They might,
13. Wright C J, Mueller C B. Screening mammography and
however, prove much more cost-effective in tackling the
public health policy: the need for perspective. Lancet
results of deprivation than either health promotion1995;pro346: 29-32
grammes which attempt the Herculean task of changing P. Women and the health care industry.
14. Foster
the unhealthy behaviours of those living in deprived Buckingham: Open University Press, 1995
15. Lidbrink E, ElfvingJ, Frisell J, Jonsson E. Neglected
circumstances, or preventive measures of unproven ef
aspects of false positive findings of mammography in
fectiveness. Not only is there virtually no empirical evi cancer screening: analysis of false positive cases
breast
dence to support the widely held belief that public health
from the Stockholm trial. British Medical Journal 1996;
312: 273-276
programmes could play a significant role in reducing
16.social
unacceptable inequalities in health between Hoare T, Thomas C, Briggs A, Booth M, Bradley S,
Friedman E. Can the uptake of breast cancer screening by
groups, but their very existence may well draw every
Asian women be increased? A randomized trial of a
one's attention away from the underlying socio-economic
linkworker intervention. Journal of Public Health
Medicine 1994; 16(2): 179-185
inequalities which so greaüy contribute to the health
status variations which health experts are now 17.
seeking
Price J H, Desmond S M, Krol R A, Losh D P, Snyder F F.
to eliminate. Comparison of three anti-smoking interventions among
pregnant women in an urban setting: a randomised trial.
Psychological Reports 1991; 68: 595-604
References 18. Garner L. The NHS: your money or your life.
Harmondsworth: Penguin Books, 1979
19. Sainsbury R, Haward B, Rider L.Johnston C, Caroline R.
1. Department of Health. Variations in health: what can
the Department of Health and the NHS do? London: Influence of clinician workload and patterns of treatment
Department of Health, 1995 on survival from breast cancer. Lancet 1995;
2. Townsend P, Davidson N, Whitehead M. Inequalities in345:1265-1270
health. Basingstoke: Penguin Books, 1988 20. Yates J. Private eye, heart and hip. Edinburgh: Churchill
3. Benzeval M, Judge K, Whitehead M, eds. Tackling Livingstone, 1995

182 J Health Serv Res Policy Volume 1 Number 3 July 1996

This content downloaded from

152.118.24.31 on Tue, 28 Sep 2021 04:55:22 UTC
All use subject to https://about.jstor.org/terms