Health Viewpoint: Policy may fail without action to tackle poverty

THE White Paper The Health of the Nation deserves a warm welcome. For the first time, clear directions for improving the health of the population have been established, and this should help in giving greater priority to disease prevention and health promotion.

Yet in placing health issues firmly on the agenda, the White Paper creates a dilemma for the Government. It is well established that the experience of health and illness is not evenly distributed. Families of manual workers have a much poorer health record than families of people in professional and managerial jobs.

A credible strategy for improving the nation's health has to acknowledge the importance of health inequalities and put forward policies for improving the relative position of people lower down the social scale. On this score, the White Paper disappoints. While much is made of the need to tackle cancers, strokes and heart disease, the White Paper fails to give adequate attention to the uneven distribution of these illnesses. Unless the concentration of poor health among the lower social groups is recognised and tackled, the strategy that has been outlined runs the risk of being merely symbolic.

It is not difficult to see why the Government has chosen to underplay the existence of health inequalities. Reducing these involves strategies that go well beyond the health service. Those in white-collar occupations may respond to messages on giving up smoking, eating a healthy diet, and taking exercise, but a different approach is needed for other groups.

The Government has to tackle the root causes of poverty and deprivation. This calls for healthy policies in areas such as housing, education, social security and the economy. Unless all citizens have secure employment, adequate housing and access to education, then the health divide will not only persist but it will widen.

This was clearly recognised by the World Health Organisation in its Strategy for Health for All by the Year 2000, on which the White Paper is based. As the WHO argued, reducing inequalities between social groups had to be central to a policy of improving the population's health. And as successive WHO analyses have shown, it follows that initiatives to change lifestyles and promote healthy behaviour have to go hand in hand with action on the economic, social and environmental influences on health.

To be fair, the Government has recognised the importance of these issues to the extent of setting up a Cabinet committee bringing together ministers from several departments to take forward work on the health strategy at a national level. This is a step in the right direction and it could result in more concerted action on the health implications of policies outside the health sector. But unless the Government is prepared to modify the direction of economic and social policy, changes to the machinery of government are merely tinkering. Like a child seeking to protect a sandcastle from the incoming tide, they can only hope to delay the inevitable.

Yet all is not lost. England has at last caught up with the rest of the UK and much of Europe in acknowledging the need to set targets for improving health. Ministers may be reluctant to follow through the logic of their analysis, but public health advocates will seize the opportunity to put health services on the agenda of all government departments.

One way forward would be to require policy initiatives to be accompanied by health impact statements. Nowhere is this more important than in relation to the Treasury, where the Chancellor is in many ways better placed to improve health than the Secretary of State for Health. Ensuring that future policies on taxation, benefits and the management of the economy help to promote the White Paper's objectives would be a more important step than anything that can be achieved in the health services.

Chris Ham is Professor of Health Policy and Management at Birmingham University.