The NHS has traditionally encouraged other bodies to tackle social inequalities. But health services can make a difference directly, not least among their own staff. Jeremy Hawker explains how

The publication of the green paper, Our Healthier Nation, and Sir Donald Acheson's updating of the Black report have given renewed emphasis to reducing inequalities in health in the UK.

Social exclusion has also been identified as a priority for action by the whole government. The NHS's usual approach to these problems is to lobby other organisations to remedy social inequalities in the belief that this will lead to a reduction in health inequalities.1 But although this approach is vital, it is important to realise that health services can do much to influence these factors directly.

Too often the relationship between social deprivation and poor health is viewed as a one-way street, with the former causing the latter. But it is clear that the health service, simply because of its size, can reduce social exclusion in ways not immediately related to the medical treatment of the individual patient.

Health and social exclusion

In many areas, people who are already at risk of social exclusion have that risk further increased by their poor health. There is scope for health interventions to break this vicious circle.

Effective family planning services can prevent unwanted pregnancies, of course, but they can also influence the age at which women have their first child, family size and child spacing. This affects women's ability to complete their education, develop their careers and control family expenditure, all of which can reduce the risk of social exclusion. Conception rates are highest in areas of social deprivation, and the recent finding that lower contraceptive use among ethnic minority women is not explained by a desire to get pregnant suggests that there is unmet need in such areas.2,3

Population Trends 1998 pointed out that the UK has one of the highest teenage pregnancy rates in the western world, and the fact that both birth and termination rates actually increased among teenagers in 1996 is evidence that we should be doing much better in this area.

Disease and exclusion

Many individuals' ability to get or keep a job or adopt a healthier lifestyle is reduced by chronic physical illness, such as heart disease, bronchitis and arthritis, or psychological illness such as depression.

Such illness is extremely common. In its 1988 survey, the Office of Population Censuses and Surveys assessed around 15 per cent of the population aged 50 to 64 as being disabled - a prevalence approximately half the self- reported figure in the General Household Survey. The prevalence of depressive disorder in the British population is estimated at 2-5 per cent.

These illnesses are more common in deprived areas. But the social effect of most of them can be reduced by medical interventions from health service staff who have sufficient time to obtain a full history of the illness and its effect on the patient's life, and who possess up-to-date clinical skills for diagnosis and treatment.

In practice, people with chronic illness have to rely on a primary care system which fails to deliver optimal medical management of chronic diseases. In addition, the areas with the highest prevalence of such diseases have fewer good services than less deprived areas.

Using the NHS organisation

As a large state-funded organisation, the NHS should be expected to play its part in the government's assault on social exclusion. Indeed, as social inequalities have such clear health effects, the NHS should be giving a lead to other organisations.

The NHS is in a position with excellent access to socially deprived populations. Three-quarters of the population visit their GP at least once a year and almost everyone sees their GP at least every five years. The success of efforts to raise awareness of entitlement to social security benefits for those attending primary care surgeries in deprived areas has already been demonstrated.4 Such interventions are a method for the health services to increase directly the income of vulnerable patients, and the scope for this is illustrated by the estimate that between£1.6bn and£3.2bn of benefits remain unclaimed each year in England and Wales.

Health inequalities and NHS staff

The NHS is Europe's largest employer and has many employees on low incomes. Not only did health inequalities (as measured by deaths) in health service employees widen between the 1970s and the 1980s, but they did so by more than those for the general population.5 Since then, the introduction of competitive tendering for many non-clinical services has had the side- effect of lowering the incomes of some of the already lowest-paid NHS staff and of weakening their job security.

If the NHS is not able to confront issues such as pay, job satisfaction and job security, it could at least attempt to ameliorate the health consequences by finding and implementing cost-effective health promotion and occupational health services, specifically targeted at low-paid health workers. This approach may even offer paybacks to the employer such as reduced sickness absence. The NHS should also consider the extent to which it helps people at increased risk of social exclusion - such as single mothers, people with disabilities and those from ethnic minorities - to enter employment in the organisation.

Many more jobs in the health service could be done by such people if more effort was made to remove barriers to their employment and if people from the relevant population groups were made more aware of such opportunities. In particular, a greater proportion of people with health-related disabilities will be expected to work in the future. If the health service is not capable of facilitating their employment, why should any other organisation or business be expected to?

The NHS in England invests£1.5bn a year in capital works. A significant proportion of this is spent on building premises to house new hospitals, community care premises and health authority offices: presumably primary care group offices can now be added to this list.

If such developments take place in deprived areas then, even though much of the capital cost is paid to people outside that area, they may give a significant boost to the local economy by providing employment and demand for service industries and public transport.

This approach is likely to be more effective if combined with local authority efforts in economic regeneration of specific local areas.

Setting local and national targets

The role of setting targets to reduce inequalities is recognised in Our Healthier Nation: certain national targets are suggested for consultation and additional local targets will be required.

Careful thought is needed in order to avoid perverse incentives which result in the widening of inequalities. If tackling inequalities is to be a priority, both health promotion and primary care services will need to be further targeted towards those in most need, who may not score so well in any cost-effectiveness analysis of unit health gain per pound sterling because they may be more difficult to reach and may need more help to change. As resources are limited, this may mean moving away from more cost-effective ways of improving health in the relatively well-off.

Preferentially improving the health of the poorest in society (the second of the government's aims) may actually slow down progress in improving the health of the population as a whole (the first aim) if this were to be measured using population averages. Appropriate national and local targets should relate directly to health improvements in socially deprived populations, and should include factors which influence the vicious circle of deprivation and ill health.

This approach will also integrate health targets with the government's wider plans to reduce social exclusion. At national level, such targets might focus on mortality by social class or for the 10 per cent of the population living in the most deprived areas of the country. Sufficiently large aggregate populations can also be constructed to allow more local targets for deaths and teenage conceptions to be monitored in deprived populations (for example, an aggregate of the more deprived enumeration districts of Birmingham).

Further local targets for deprived areas should include smoking rates, targets relating to the standards of chronic disease management in primary care, and targets relating to the standard of contraceptive services. As there is evidence that inequalities in health have actually widened in the UK in recent years, we cannot run the risk that we will achieve more general health targets while further widening this gap.


The recent approach to reducing health inequalities has added to lobbying - and working with - other organisations that can influence the causes of social inequality. The NHS can directly influence social inequalities in many areas, including initiatives to break the vicious circle of health inequalities.

There are also opportunities to show leadership to other agencies which could have an even larger influence. Further work is urgently required to refine this approach, which should then become part of both the national strategy and local health improvement plans.

The NHS cannot do it all on its own, but those of us who work in this field must ensure that we play our part in tackling inequality and exclusion and not simply be seen as passing responsibility on to others.


1 Whitehead M, Scott-Samuel A, Dahlgren G. Setting targets to address inequalities in health. Lancet 1998; 351 (9111): 1279-82.

2 Wood R. Subnational variations in conceptions. Population Trends 1996; 84: 21-7

3 Raleigh V, Almond C, Kiri V. Fertility and contraception among ethnic minority women in Great Britain. Health Trends 1998; 29: 109-13.

4 Jarman B. Giving advice about welfare benefits in general practice. Br Med J 1985; 290 (6467): 522-4.

5 Balarajan R. Inequalities in health within the health sector. Br Med J 1989; 299 (6703): 822-5.

6 Marsh A, McKay S. Poor Smokers. London: Policy Studies Institute, 1994.

Cigarettes: low incomes going up in smoke

Cigarette smoking shows a clear association with social class and is particularly high in younger pregnant women from lower-income groups. Apart from being the single most important medical factor in explaining excess mortality associated with deprivation, smoking is itself an exacerbating factor in income inequality.

As the cost of smoking 20 cigarettes a day is the same no matter what an individual earns, a larger proportion of resources is required to support this habit for people on low incomes.

It has been estimated that three-quarters of couples on income support spend a fifth of the adult component of this money on cigarettes.6

This unequal burden will have recently increased in the UK because of the otherwise welcome rise in cigarette taxation. Effective measures to help this group give up smoking exist and would directly increase their disposable income, according to the NHS Centre for Reviews and Dissemination.

Such interventions need to be better targeted at low-income groups, which are more difficult to reach and may require more help to change. As we have made life more difficult for poor smokers by increasing the tax on a substance that they are physically and psychologically addicted to, we should at least make sure that we offer them realistic help to overcome their addiction. Other addictive substances such as alcohol and illegal drugs may exert a similar effect in promoting social exclusion.