The Review Health inequalities in primary care: time to face justice

‘Don't take offence if we tell you to lose that debate so far has been the utilitarian spokesperson subsequently denied weight or stop smoking or drinking. You position, convincingly put forward by suggestions that concerns for the politics of need to face facts and take responsibility’ , authors of The Spirit Level , and utilised winning votes among older people might be asserted Professor Steve Field, then Chair of subsequently by David Cameron in his acting as a greater influence upon social the Royal College of General Practitioners, promotion of the Big Society, 6 that ‘equality policy than concerns for social justice. in an article published in the Observer back is better for everyone’. 7 Yet Marmot’s The same Department of Health in the summer of 2010. He continued: ‘ every allusions to fairness and social justice spokesperson asserted that ‘the Health Act day we [GPs] are confronted with the harm prompt consideration of another debate has given the NHS its first ever duty to caused by smoking, excessive alcohol that has not yet occurred: a debate in terms reduce health inequalities’. 14 But the Health consumption, and obesity.’ 1 In the same of rights, opportunities, and justice. 8 That we and Social Care Act in fact only ever refers newspaper the following week Professor are still limited to talking about ‘health to ‘inequalities between patients with Field was upbraided by Professor Sir inequalities’ in the UK signifies a key respect to their ability to access health Michael Marmot, Chair of the World Health deficiency in our discussions. An important services’ and/or ‘the outcomes achieved for Organization’s (WHO’s) Commission on distinction exists between health them by the provision of health services’. Social Determinants of Health: inequalities and health inequities .9 That is, Equality in service access and outcomes is between those differences in health not at all the same as equity or equality in ‘Simply telling people to behave more outcomes attributable to biological variation health: the Health Act permits health responsibly is no more likely to be effective or free will (inequalities), and those inequities to persist. No surprise perhaps. than telling someone who is depressed to determined by the external environment Recall Equity and excellence: Liberating the pull his socks up ... smoking, obesity, and and factors beyond an individual’s control NHS , the government white paper that heavy drinking are causes of ill-health, but (inequities). 10 Inequities are deemed unjust eventually became the Health and Social what are the causes of these behaviours?’ 2 or unfair by most definitions; inequalities Care Act. Despite its prominent appearance are not necessarily so. 11 The distinction is in the title, ‘equity’ was never cited in the Marmot was alluding to the social more than words: we need not worry about white paper as an aspiration and no determinants of health, the ‘poverty, health inequalities if we know they are mention was ever made of strategies that exploitation, oppression, and injustice’ inevitable or not unfair (for example, the might improve equity in wealth or health. described in his influential WHO report. 3 It is health inequality between young and old), ‘Inequity’ was never mentioned, nor, these determinants that result in health but it is imperative that we acknowledge unsurprisingly, were ‘justice’, ‘injustice’, inequalities; causing for instance, male life and address unequal health distributions ‘fairness’, or ‘unfairness’. 15 expectancy in the poorest parts of Glasgow that are avoidable and unjust (such as to be just 54 years, while in affluent areas of between richer and poorer members of our THE ROLE OF HEALTH CARE IN HEALTH the same city it is 82 years. 4 Acknowledging society). INEQUITIES that people with less money and less We should be concerned by the ease with education are likely to have less control over POLITICAL AVOIDANCE OF HEALTH which equity is shifted to the fore when it is their lives and their health behaviour will EQUITY useful for justifying healthcare policy, then help us to avoid blaming victims and thereby Acknowledging this might have enabled us allowed to slip away when it becomes a contributing to injustices in practice. But to immediately perceive the ill-judgement in prospect too challenging to confront. And other than aiming to empower, not Health Secretary Andrew Lansley’s we should be concerned by the failure to admonish, patients to change unhealthy announcement earlier this year that adequately account for health inequities in behaviours, and treating their physical regional healthcare funding should be healthcare planning and provision. consequences, what is the role for GPs (and based upon the age of the local population, Over 40 years ago Julian Tudor Hart GP leaders) in tackling health inequalities? rather than indices of deprivation. 12 The described the inverse care law. It states that announcement elicited little controversy the availability of health care tends to vary DISTINGUISHING INEQUITIES FROM and one medical writer was ‘struck by the inversely according to a population’s health INEQUALITIES absence of reaction to Andrew Lansley’s needs. This is a sorry reflection of social ‘Inequalities that are preventable by claim. He seems to have got clean away injustice, but not necessarily a major reasonable means are unfair. Putting them with it’. 13 A Department of Health determinant of health inequity: breaking right is a matter of social justice.’

Michael Marmot again, in his review of health inequalities in England: “We should be concerned by the ease with which equity is shifted to the fore when it is useful for justifying ‘A debate about how to close the health gap has to be a debate about what sort of society healthcare policy, then allowed to slip away when it people want.’ 5 becomes a prospect too challenging to confront.” Perhaps the most influential argument in

428 British Journal of General Practice, August 2012 ADDRESS FOR CORRESPONDENCE “As GPs we hold a unique position as witnesses to Andrew Moscrop Oxford University, Department of Primary Health unjust health outcomes ... Initiating and impelling the Care, 2nd Floor, 23–38 Hythe Bridge Street, Oxford, justice debate about health inequities and their OX1 2ET, UK. E-mail: [email protected] determinants is an urgent and important role ...”

Hart’s law will not resolve the ‘poverty, the injustices and to engage in meaningful exploitation, oppression, and injustice’ that debate about how they might be redressed constitute the principle social determinants is itself a decision of dubious morality. of health. Yet the law does not describe a Initiating and impelling the justice debate static system: as (socially-determined) about health inequities and their population health declines and availability of determinants is an urgent and important health care reduces, the strength of health role that GPs (and GP leaders) surely have care as a health determinant increases. As an obligation to take on. the situation of social injustice deteriorates, Hart’s law becomes increasingly important. Andrew Moscrop, And the situation in Britain is deteriorating: GP, Department of Primary Health Care, University health inequities have worsened since of Oxford, Oxford. Hart’s original work and they continue to get worse. 16 DOI: 10.3399/bjgp12X653660 In the long term, the greatest impact of the NHS upon health inequities should be by way of funding through more progressive REFERENCES Organisation Regional Office for Europe, 1990. taxation; leading to greater wealth equity 1. Field S. Don’t take offence if we lecture you on http://whqlibdoc.who.int/euro/- with consequent health benefits. Here again how to stay alive and healthy. The Observer 1993/EUR_ICP_RPD_414.pdf (accessed 26 Julian Tudor Hart has exposed the ease with 2010; 8 Aug: Jun 2012). which social justice is overlooked. http://www.guardian.co.uk/commentisfree/20 10. World Health Organization. Health impact Discussing the perceived problem of ‘how to 10/aug/08/steve-field-patient-responsibility- assessment: glossary of terms used. health (accessed 1 Jun 2012). http://www.who.int/hia/about/glos/en/index1.h fund a just healthcare system’ recently he 2. Marmot M. Ignorance is as big a killer as tml (accessed 26 Jun 2012). dismissed recourse to the proposed obesity. The Observer 2010; 15 Aug: 11. Macinko JA, Starfield B. Annotated means-tested direct charges to patients http://www.guardian.co.uk/commentisfree/20 Bibliography on equity in health, 1980 –2001. (co-payments) and reminded us that 10/aug/15/michael-marmot-health-wellbeing Int J Equity Health 2002; 1: 1. (accessed 1 Jun 2012). funding from properly progressive taxation 12. Williams D. Lansley: CCG allocations should would already be means-tested, would 3. World Health Organization Commission on be based on age, not poverty. Health Serv J avoid an added tax upon the sick, and would Social Determinants of Health. Closing the 2012; 26 Apr: gap in a generation: health equity through http://www.hsj.co.uk/news/finance/lansley- have the further benefit of reducing wealth action on the social determinants of health. ccg-allocations-should-be-based-on-age- (and consequently health) inequities. 17 Final report of the Commission on Social not-poverty/5044219.article (accessed 26 Jun Determinants of Health. Geneva: WHO, 2008. 2012). www.who.int/social_determinants/final_repor IF NOT US, WHO? 13. Hawkes N. Allocation of NHS resources: are t/en/index.html (accessed 1 Jun 2012). Justice-based discussion about the health some patients more equal than others? BMJ 4. Davey Smith G, Kreiger N. Tackling health 2012; 344: e3362. consequences of social processes and inequities. BMJ 2008; 337: a1526. resource distributions is a necessary 14. Campbell D. NHS spending plan hits poorer 5. Marmot M. Strategic review of health companion to the argument that equality is areas, critics claim. The Guardian 2012; 22 inequalities in England post-2010. Marmot May: better for everyone. It has the potential to review final report. London: University College http://www.guardian.co.uk/society/2012/may/ ensure that health inequities are neither London, 2011. 22/nhs-spending-plan-hits-poorer- inappropriately exploited nor discounted in www.ucl.ac.uk/gheg/marmotreview/Documen areas?INTCMP=SRCH (accessed 26 Jun ts (accessed 1 Jun 2012). health policy proposals. And it could drive a 2012). 6. Cameron D. The Big Society. Speech. Nov 10, vital moral imperative into tackling social 15. Secretary of State for Health. Equity and 2009. excellence: liberating the NHS . London: determinants of health that lie beyond the http://www.conservatives.com/news/speeche Department of Health, 2010. remit of the health services such as s/2009/11/david_cameron_the_big_society.as http://www.dh.gov.uk/en/Publicationsandstati education, employment, housing and — px (accessed 26 Jun 2012). stics/Publications/PublicationsPolicyAndGuid most crucially — taxation. Justice is a 7. Wilkinson R, Pickett K. The spirit level: why ance/DH_117353 (accessed 1 Jun 2012). powerful concept, but one that more equal societies almost always do better . 16. Thomas B, Dorling D, Smith GD. Inequalities London: Allen Lane, 2009. governments will only confront if it is part of in premature mortality in Britain: 8. Roberts MJ, Reich MR. Ethical analysis in observational study from 1921 to 2007. BMJ a public agenda with which they can align. public health. Lancet 2002; 359(9311): 2010; 341: c3639. As GPs, whether we like it or not, we hold a 1055 –1059. 17. Hart JT. How to afford a just health care unique position as witnesses to unjust 9. Whitehead M. The concepts and principles of system. Br J Gen Pract 2012; 62(596): health outcomes. Failure to acknowledge equity in health. Copenhagen: World Health 123 –124.

British Journal of General Practice, August 2012 429