Independent Inquiry into Inequalities in Health Report Chairman: Sir Donald Acheson £19.50 published by The Stationery Office as ISBN 0 11 322173 8 Independent Inquiry into Inequalities in Health Report Contents Contents The Inquiry was chaired by: Terms of Reference Preface List of Tables and Figures Synopsis Part 1 Introduction Inequalities in Health: The Current Position Part 2 Reducing Inequalities in Health Areas for Future Policy Development 1. Poverty, Income, Tax and Benefits 2. Education 3. Employment 4. Housing and Environment 5. Mobility, Transport and Pollution 6. Nutrition and the Common Agricultural Policy 7. Mothers, Children and Families 8. Young People and Adults of Working Age 9. Older People 10. Ethnicity 11. Gender The National Health Service List of Recommendations References Annexes A. Letter from the Minister for Public Health (10 July 1997) B. Process of the Inquiry C. Acknowledgements D. Papers, Submissions and Evidence to the Inquiry Independent Inquiry into Inequalities in Health Report Independent Inquiry into Inequalities in Health The Inquiry was chaired by: Sir Donald Acheson, Chairman of the International Centre for Health and Society at University College, London. Scientific Advisory Group The Inquiry was overseen by a Scientific Advisory Group. The members of the Group were: Professor David Barker FRS, Director of the Medical Research Council's Environmental Epidemiology Unit, University of Southampton Dr Jacky Chambers, Director of Public Health, Birmingham Health Authority Professor Hilary Graham, Director of the Economic and Social Research Council's Health Variations Programme, Lancaster University Professor Michael Marmot, Director of the International Centre for Health and Society, University College, London Dr Margaret Visiting Fellow, the King's Fund, London Secretariat Administrative Secretary: Dr Ray Earwicker, seconded from the Department of Health Scientific Secretary: Dr Catherine Law, seconded from the Medical Research Council's Environmental Epidemiology Unit, University of Southampton Statistical Adviser: Frances Drever, seconded from the Office for National Statistics Independent Inquiry into Inequalities in Health Report Terms of Reference Terms of Reference 1. To moderate a Department of Health review of the latest available information on inequalities of health, using data from the Office for National Statistics, the Department of Health and elsewhere. The data review would summarise the evidence of inequalities of health and expectation of life in England and identify trends. 2. In the light of that evidence, to conduct - within the broad framework of the Government's overall financial strategy - an independent review to identify priority areas for future policy development, which scientific and expert evidence indicates are likely to offer opportunities for Government to develop beneficial, cost effective and affordable interventions to reduce health inequalities. 3. The review will report to the Secretary of State for Health. The report will be published and its conclusions, based on evidence, will contribute to the development of a new strategy for health. Independent Inquiry into Inequalities in Health Report Preface Preface This Report addresses an issue which is fundamentally a matter of social justice; namely that although the last 20 years have brought a marked increase in prosperity and substantial reductions in mortality to the people of this country as a whole, the gap in health between those at the top and bottom of the social scale has widened. Yet there is convincing evidence that, provided an appropriate agenda of policies can be defined and given priority, many of these inequalities are remediable. The same is true for those that exist between the various ethnic groups and between the sexes. In July 1997, I was invited by the Secretary of State for Health to review and summarise inequalities in health in England and to identify priority areas for the development of policies to reduce them. To accomplish this task, I have been aided by a small group of scientists. This Report is the result of our work together. In this work, we have consulted widely and drawn on the expertise of a range of colleagues whose names are acknowledged in the Report. We also acknowledge and have built on the work of those who have gone before us. We mention in particular Sir Douglas Black's ground breaking report "Inequalities in Health". We have also found inspiration in the work of the World Health Organisation which, in its European "Health for All" Policy, gives precedence above all other objectives to the promotion of equity in health within and between countries. There have been many relevant developments between the appointment of the Inquiry and our submission of this Report to Ministers. From its earliest days in office, the Government has expressed its concern about inequalities in health and in February 1998 translated this concern into a central premiss of its consultation paper "Our Healthier Nation". This has been followed not only by the 1998 Budget but by a succession of consultation documents and White Papers relevant to our inquiry. As our work developed, it has become clear that the range of factors influencing inequalities in health extends far beyond the remit of the Department of Health and that a response by the Government as a whole will be needed to deal with them. We believe that the policies and areas for policy development which we have identified from the available evidence, comprise an effective agenda. Its components are congruent and mutually reinforcing. We are convinced that if this agenda is implemented it will make a major beneficial impact on inequalities in health. We hope that it will also provide a sound basis for policy development well into the next millennium. At this point, the scientific work of the Inquiry is done. We commend the Report to the elected Government as a significant contribution to social equity worthy of urgent consideration. It is now for the Government to decide the rate of implementation and the affordability of our recommendations. Sir Donald Acheson September 1998 Independent Inquiry into Inequalities in Health Report List of Tables and Figures List of Tables and Figures TABLES Table Occupations within social class groupings 1: Table European standardised mortality rates, by social class, selected causes, men aged 20-64, England and Wales, 2: selected years Table Age-standardised mortality rates per 100,000 people, by social class, selected causes, men and women aged 35-64, 3: England and Wales, 1976-92 Table Estimates of the numbers of lives and working man-years lost per year, selected causes, men aged 20-64, England 4: and Wales, 1991-93 Table Unemployment rates, by ethnic group, Great Britain, Winter 1997/98 5: Table Proportion of dwellings by household tenure, England, 1938 and 1997 6: Table Household tenure, one person households, England, 1984 and 1995/6 7: Table Risk of being a victim of crime, by type of area, England and Wales, 1995 8: Table Mode of travel to work, England, 1991 9: Table Standardised mortality ratios, by country of birth, selected causes, men and women aged 20-69, England and 10: Wales, 1989-92 FIGURES Figure 1: The main determinants of health Figure 2: Socioeconomic circumstances and health outcomes Figure 3: Annual major accident rates, by age and social class, England 1996 Figure 4: Prevalence of mental health problems, by social class, men and women aged 16-64, Great Britain, 1993-94 Figure 5: Real household disposable income, before housing costs, United Kingdom, 1961-1994 Figure 6: Proportion of people whose income is below various fractions of average income, United Kingdom, 1961-1995 Figure 7: Proportion of the working age population without qualifications, by gender and ethnic group, Great Britain, Spring 1997 Figure 8: Unemployment rates, population age 16 years and over, England and Wales, 1961-95 Figure 9: Households with access to a car or a van, Great Britain, 1971-1996 Figure Standardised mortality rates, by gender, all ages, England and Wales, 1971-96 10: Figure Age-specific mortality rates, children, England and Wales, 1991-95 11: Figure Prevalence of major accidents, by gender and age, England, 1996 12: Figure Indices of average earnings, basic pensions and Income Support for those aged 75 and over, United Kingdom, 13: 1980-96 13: 1980-96 Figure Educational attainment and free school meals, England, 1996/97 14: Figure Projected road traffic growth, Great Britain, with low and high forecasts 15: Figure Standardised mortality rates, by Townsend quintile, males and females, England, 1993-95 16: Figure GP health promotion claims, by Jarman (UPA) score of health authority, London Boroughs, October 1995 17: Figure Rates of coronary artery bypass grafts and coronary angioplasty, by Jarman score, England, 1995/1996 18: Figure Distance from resource allocation target, all health authorities, England 1998/99 19: Independent Inquiry into Inequalities in Health Report Synopsis Synopsis Our task has been to review the evidence on inequalities in health in England, including time trends, and, as a contribution to the development of the Government's strategy for health, to identify areas for policy development likely to reduce these inequalities. We carried out our task over the last 12 months, drawing on scientific and expert evidence, and peer review. Although average mortality has fallen over the past 50 years, unacceptable inequalities in health persist. For many measures of health, inequalities have either remained the same or have widened in recent decades. These inequalities affect the whole of society and they can be identified at all stages of the life course from pregnancy to old age. The weight of scientific evidence supports a socioeconomic explanation of health inequalities. This traces the roots of ill health to such determinants as income, education and employment as well as to the material environment and lifestyle. It follows that our recommendations have implications across a broad front and reach far beyond the remit of the Department of Health.