The government is determined to reduce health inequalities by 2010, but this requires a concerted effort from all local agencies in the human workshop.

If health secretaries went to every Department of Health report's launch, they would not have time to do anything else. But health inequalities are a priority for Alan Johnson. He took time out of his busy schedule for Health Inequalities: progressand next steps and at the launch event emphasised the importance of the issue.

Supporting Mr Johnson on the platform were NHS North West regional director of public health Ruth Hussey, journalist and commentator Polly Toynbee and epidemiologist par excellence Professor Sir Michael Marmot, who gave presentations to an audience of professionals from health and local government, academics and experts.

Alan Johnson's presence tells us two things: that the government's commitment to the difficult, long-term plans for addressing health inequalities remains strong. And the passion of Mr Johnson's address at the launch shows that for this health secretary, this is a central - possibly the central - issue for the DH, the NHS and a range of government and adjacent agencies.

Ambitious goal

Indeed, such is Mr Johnson's personal commitment that when he was launching Lord Darzi's NHS review High Quality Care for All in Parliament, he emphasised again the issue of health inequalities.

The government has set itself a highly ambitious goal on health inequalities: cutting by 10 per cent the gap in health outcomes, as measured by infant mortality and life expectancy at birth by 2010 (see below).

Mr Johnson spoke with passion when he described the drop in life expectancy by one year at every tube station going eastbound on the Jubilee line from Westminster to Canning Town. He identified three fronts for action: addressing the wider determinants of health; promoting good health and lifestyle choices; and improving the quality of local services. Housing, employment, education and transport are all, he noted, "strong determinants of health inequalities" and much work was being done to tackle the causes of poverty and disadvantage. "Life chances are determined early, especially in gestation (by parental smoking and drinking habits), with the resulting low birth weight raising the likelihood of behavioural, schooling and health problems."

Accident rates These determinants shape family life and the domestic environment. Mr Johnson cited studies that showed that by the age of three, 50 per cent of our language is in place. Deprived children hear 13 million words by that age, compared with 45 million words in more affluent families. He said that "what starts as lack of vocabulary can translate into under-achievement".

Health inequalities are reflected in a catalogue of grim figures across the wider determinants, which expose the size of challenge in meeting the target.

Children at risk

Despite national rates of accidents falling dramatically, deprived children are 13 times more likely to die of an unintentional injury and 37 times more likely to face exposure to smoke or fire. Children in the 10 per cent of most deprived wards are three times more likely to be hit by a car than the 10 per cent in the least deprived.

One way of tackling this is through better, more specialised support for multi-problem families such as Sure Start children's centres. These aim to address and support "hard to reach" groups with family intervention projects. This work has proved a "huge success" in Mr Johnson's estimation.

He also noted the importance of work and of good-quality jobs: people in work have better health and those in good jobs have the best health. The long-term unemployed are 35 times more likely to commit suicide. Nine out of 10 people on incapacity benefit want and expect to return to work, but seven out of 10 are more likely to die than return to work.

A new "fit for work" service will intervene early to try to help this group back to work quickly. He also touched on mental health, citing figures that more than one in six people have mental health problems at any one time. Access to psychological therapies will improve, he predicted, with the 3,600 extra therapists in training.

Health and well-being

The second front, said Mr Johnson, was to do even more to promote good health. He singled out smoking as still the biggest killer: with 87,000 related deaths a year, it is the single most powerful health determinant. Rising obesity could, he added, diminish the health gains of the last 60 years. Both smoking and obesity are more prevalent in more disadvantaged groups and areas.

Mr Johnson told the audience that "promoting health and well-being is the raison d'être of the NHS". As well as more money for services to help people give up in deprived areas, he implied there will be further regulations on how cigarettes are marketed and sold.

Disadvantaged communities have higher levels of alcohol-related mortality but alcohol treatment services, which could prevent hospital admission, remain patchy and access to specialist treatment varies greatly across the country, with capacity to treat one in 13 in London, but just one in 113 in Newcastle. Also, schemes such as Gym For The Future seek to build physical activity into daily lives.

On the third front, quality of primary care, Mr Johnson emphasised the importance of access, since those with limited access have the lowest life expectancy. People in poorer areas are least likely to be able to book access and are more likely to be dissatisfied with their local doctor.

Emphasising the government's extra£250m to provide 112 new GP practices in the most under-doctored areas, Mr Johnson took the chance to deny criticisms from the British Medical Association and the Conservative Party that new GP-led centres would threaten existing GP practices: he reiterated that this was additional investment for increased capacity.

Increasing life expectancy

Life expectancy for men in the target spearhead areas has increased by over two and a half years since 1995-97 and in spearhead areas, mortality among the under-75s from cancer and cardiovascular disease has fallen faster than in England as a whole. Infant mortality rates are at historic low levels, including for the routine and manual groups - the focus of the target.

Developments against the target and the wider determinants are reported in Tackling Health Inequalities: 2007 status report on the programme for action.

Improving further the health of disadvantaged groups and areas and narrowing the health gap will require:

  • focusing local communities on meeting the 2010 target - and looking to set new objectives beyond 2010;

  • working more closely across government to ensure a coherent approach;

  • promoting leadership at local level to make change happen;

  • using - and further enhancing - the available tools, incentives, accountabilities and leadership;

  • building the evidence base to support policy and delivery.

As far as the Department of Health is concerned this means:

  • scaling up the national support team on health inequalities;

  • providing an improved version of the intervention tool;

  • developing programmes to support leadership development;

  • investing in the capacity and capability of local third sector organisations'.

Stronger partnerships For the NHS, the document emphasises the significance of lifestyle behaviours in relation to health, namely smoking, diet, exercise and alcohol, and signposts the commissioning of a broader research programme into understanding the reasons underlying healthy and unhealthy behaviours. It notes the propensity for these behaviours to "cluster" and recognises how hard it is to change them.

Cross-government work, including work with local government, on health inequalities will focus on five key areas:

  • investing in early years and parenting;

  • using work to improve health and well-being;

  • promoting equality;

  • developing mental health services further;

  • co-ordinating action nationally and locally.

This means making the best use of cross-sector tools such as joint strategic needs assessments, local strategic partnerships and local area agreements, to build a stronger partnership between the NHS, local government and other agencies.

Further work across government will help to develop:

  • appropriate incentives for organisations to invest in health inequalities programmes, including action with long payback times;

  • a new health inequalities public service agreement target and future funding strategy;

  • joint accountability for a future public service agreement.

Building local success

Health Inequalities: progress and next steps emphasises the necessity of effective local action and draws on the work of the national support team for health inequalities, with a list of principles to inform local success.

Some local authorities and PCTs have already started to apply many of these principles, including the six councils who won beacon council status in 2008 for their clear vision, excellent services and willingness to innovate. These councils have a special role, sharing good practice with other councils and encouraging its adoption.

The local principles for success include the following strategies:

  • Adopting a strategic, evidence-based approach. This means using available local data to understand the gap and what is causing it, considering the drivers of health inequalities and spotting the organisations with the levers to address them. It means working with these organisations, focusing on long-term causes as well as short-term needs of those already experiencing the effects of health inequalities and achieving a fit with other NHS and local government programmes, such as economic regeneration.

  • Scaling action to the size of the problem locally. Developing an action plan based on the analysis set out in the joint strategic needs assessment and evidence-based interventions derived from the health inequalities intervention tool, with local measures and monitoring built into operational plans and local area agreements.

  • Leading from the top. Working with chief executives and directors of finance, commissioning and primary care, clinical leadership, housing, planning and other departments, as they all play an important part. Public health can advise but cannot deliver on its own.

  • Ensuring the quality and quantity of primary care. Making sure that in disadvantaged areas, services meet local needs and are well organised. Support for proactive development should be possible both generically (eg strengthening practice management) and for specific priorities (eg managing cardiovascular disease or chronic obstructive pulmonary disease programmes).

  • Actively seeking out people who have a disease or are at high risk but are not accessing services early enough. Ensuring those with multiple needs are not being "exception reported" for the quality and outcomes framework. It also involves using a variety of local data to ensure the health needs of disadvantaged populations are being met.

  • Capitalising on neighbourhood and community infrastructures to engage individuals, families and communities. Targeting in particular those who are "seldom seen, seldom heard" in services, to ensure services are responsive and helping to motivate and support health-seeking behaviour.

  • Ensuring that partnerships are effective. Not only at board level, but also for middle management and frontline staff. Different organisations should agree priorities, explicitly share leadership and responsibility and take concerted action.

  • Considering and addressing workforce implications. Understanding what needs to be done locally, by whom and which resources are needed, taking into account the necessary scale of activity and balancing the skill mix to obtain cost-effectiveness and sustainability of systems.

  • Innovating. Always looking for new ways to understand problems and deliver solutions.


By 2010, the public service agreement target is to reduce inequalities in health outcomes by 10 per cent, as measured by infant mortality and life expectancy at birth. Under this sit two more detailed targets:

  • Starting with children under one, to reduce by at least 10 per cent the gap in mortality between routine and manual social groups and the population as a whole by 2010.

  • Starting with local authorities, to reduce by at least 10 per cent the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators (the "spearhead" group) and the population as a whole. This is also to be achieved by 2010.


In March 2008 six authorities were awarded beacon status for their work in reducing health inequalities. Each authority has a unique story to tell but the beacons also have core features in common. These include:

  • Strong leadership. For instance, Coventry city council has cross-party member leadership for health inequalities, plus a dedicated Health Development Unit to drive forward actions including anti-obesity initiatives, sexual health services, a community nutrition service and work on infant mortality.

  • Effective partnerships. For example, Sunderland city council has developed innovative strategies to promote "wellness" through unique partnering arrangements with the teaching primary care trust.

This has resulted in city-wide coverage of wellness facilities, comprehensive referral across 100 per cent of GP practices and jointly developed pathways for a range of conditions as well as whole-family lifestyle interventions.

  • Accessible services. Merseyside Fire and Rescue Authority's advocate scheme, coupled with its strong brand, ensures its home fire safety checks reach up to 100,000 households per year. The authority uses this opportunity to work imaginatively with partners to assist those most vulnerable to inequalities.

  • Rigorous data analysis - for example, Derwentside district council employed an epidemiologist to carry out lifestyle surveys and a health equity audit, linking health inequality targets to specific interventions and activities to achieve maximum impact.

  • Community focus. For instance, Sheffield city council takes a neighbourhood-based approach to service design and delivery, using detailed mechanisms for data capture and analysis to inform a range of targeted actions for local partners, precisely tailored to address the needs of their diverse communities.

  • Innovation. The London Borough of Greenwich has created a course, Health, Everyone's Business, for all staff, a healthy urban planning framework, online cognitive behavioural therapy and the Kick the Habit initiative, which uses a local football club to target smoking cessation activity for male manual workers. Over the next year, all six reducing health inequalities beacons will be convening a range of conferences, networks, seminars, interactive learning events, small-group mentoring and one-to-one support activities.

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