HEALTH ECONOMICSHealth Econ. 19: 881–885 (2010)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hec.1637

EDITORIAL

I DREAMED A DREAM: ENGLAND REDUCES HEALTHINEQUALITIES AND WINS THE WORLD CUP

STEPHEN BIRCHa,b,�

aMcMaster University, Hamilton, Ont., CanadabUniversity of Manchester, Manchester, UK

Fair Society, Healthy Lives: Strategic review of health inequalities in England post 2010 (The Marmotreview) is the latest report on social inequalities in health to emerge from the United Kingdom. Likeattempts to win the football (soccer) world cup, strategies for reducing health inequalities happen everyfew years in England and have generally had the same lack of success. Commissioned by the Secretaryof State for Health in England to propose the most effective evidence-based strategies for reducinghealth inequalities in England from 2010, the terms of reference covered identifying evidence mostrelevant to future policy for reducing health inequalities, translating evidence into practice and advisingon possible objectives and measures for policies. The result is a 242 page report produced by the team of11 commissioners (hereafter referred to as the England XI) ‘captained’ by Michael Marmot with asubstantial backroom staff of individuals (Strategic review of health inequalities in England post 2010,2010).

Setting aside the rather odd subtitle to the report (how can individuals reporting at the start of 2010review health inequalities post 2010 without the help of a time machine?), the starting point for thereport is the normative position that health inequalities which are preventable by reasonable means areunfair and that ‘putting them right’ is a matter of social justice. From this emerges a ‘central ambition’to ‘create conditions for people to take control over their own lives’–something akin to Fantine’s dreamin Les Miserables. The report documents a vast evidence based on social inequalities in health in the UKthat have persisted and even increased despite over 60 years of a comprehensive publicly funded health-care system and over 30 years of national reports producing policy recommendations for the reductionin these inequalities (Black et al., 1980; Acheson et al., 1998).

I HAD A DREAM MY LIFE WOULD BE, SO DIFFERENT FROM THIS HELL I’M LIVING

The call for action is clear and explicit. Reducing health inequalities ‘is a matter of fairness and socialjustice’ and action taken to do so ‘will benefit society in many ways’ namely, the economic benefits(avoiding productivity losses, reduced tax revenues, higher welfare payments and health-care costs) in‘reducing losses from illnesses associated with health inequalities’. The England XI go on to identify awide range of interventions with evidence of effectiveness. But as with previous evidence-based reports,the evidence relates to the interventions improving the position of the poorest or sickest groups in

*Correspondence to: Room CRL 203, Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main StreetWest, Hamilton, Ont., Canada L8S 4K1. E-mail: birch@mcmaster.ca

Copyright r 2010 John Wiley & Sons, Ltd.

society, not evidence of reducing social inequalities in health – a leap of faith common to previousreports (Birch, 1999).

The report introduces the concept of proportionate universalism, which may be seen as an attempt toforce ‘outcome effectiveness’ into an ‘inequalities effectiveness’ framework. Proportionate universalismadopts the social gradient in health as the focus and argues that to reduce the steepness of the gradient,health actions must be universal, not targeted, but with a scale and intensity that is proportionate to thelevel of disadvantage. This is a sort of dose–response notion where those at the bottom of thedistribution need more of the ‘health action’ than those higher up the distribution.

This reminds me of my first vacation outside the UK as a child spent in France. My father, a veteranof World War 2 and suspicious of all things ‘foreign’, had trouble in communicating with the French-speaking waiter, as he tried to order fish and chips in English. His strategy was to repeat his order louder(a larger dose will get a better response?) and ended up with a plate of frogs’ legs and further contemptfor ‘everything foreign’!

The point is that giving bigger doses to the poor of what benefited the rich is no guarantee ofequal benefits, never mind proportionately higher benefits for the poor. Policies aimed at smokingcessation are perhaps good examples of proportionate universalism (or the English abroad) – withthose non-responders (usually poorer groups) being targeted with ‘bigger doses’ instead of effortsto understand why they smoke which may be very different from the reasons why people smokehigher up the social scale (Oakley, 1994; Graham, 1994; Kooiker and Christiansen, 1995). In thisway, proportionate universalism has resulted in inverse proportionate outcomes with smoking cessationbeing larger in social groups where the prevalence is smaller. Hence, social inequalities in smokingincrease.

Grossman (1972) identified both consumption and investment ‘benefits’ as outcomes of healthproduction. This implies that individual behavior with respect to health responds to the value to theindividual of the expected future health change. The prospect of more years in poverty for the poor isunlikely to provide the same expected utility as the prospect of the same number of additional ‘goldenyears’ for the middle classes with their suburban homes, occupational pensions and large social supportnetworks. Lest we forget – this is a country that redistributes wealth from the poor to the rich underbanners such as tax exempt savings plans for retirement. Not only do the rich have more to save, the taxsaving per pound contributed is greater for the rich because of the progressive nature of the income taxsystem. A little bit of Grossman and a sprinkling of common sense show that not giving up smokingmay be a perfectly rational decision for the poor. After all, empowering people to take control over theirown lives is what the England XI are pursuing. But these lives are intrinsically linked to thecircumstances in which they work, rest and play. This is very different to giving them control over somemythical life to which they can never reasonably aspire, given the structure of society.

Notwithstanding these structural issues, the difference in health between smokers and non smokershas also been found to be greater among better off groups (Davey Smith and Shipley, 1991; Birch et al.,2000, 2005). In other words, the rate of return, in terms of health gain, appears to have a social gradientin favor of the better off. Social inequalities in both the quantity and value of future health thereforerepresent double jeopardy for the poor. Even if we somehow achieve equal effectiveness in quitting, wemight still expect health inequalities to increase.

The other original contribution of the England XI is the suggestion that policy developments must bebased on the recognition that social inequalities in health and climate change are inextricably linked. Noevidence is provided to support this claim (either from the University of East Anglia climatologists orothers!) or to establish causality other than what has been termed ‘colloquial evidence’ (an attempt byCulyer and Lomas (2006) to give credibility to expert opinion long after it was discredited in thescientific literature). Does this mean that any climate change increases social inequalities in health, orare there some climate changes that will reduce social inequalities? The idea is fascinating, particularlysince natural disasters (usually blamed on climate change) tend to be a last bastion of equality within the

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Copyright r 2010 John Wiley & Sons, Ltd. Health Econ. 19: 881–885 (2010)

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communities in which they occur. When the tsunami hits, the waves don’t pick out the poor for specialtreatment.

What about those economic benefits that represent a major rationale for action? The England XIfeared making ‘financially costly recommendations’ even though it was suggested to them that‘economic calculations would be crucial’. As with other reports they chose to ignore these costs. Insteadthey justify their recommendations, whatever their cost, by considering ‘the costs of doing nothing’. Mywife has tried this argument during the winter sales but VISA still informs me of the costs of doingsomething and expects the bill to be paid!

Suppose for the time being that there would be an available supply of whatever funds are needed fortheir policy prescriptions (back to dreaming the dream). There is no evidence that the identifiedeconomic benefits (costs of doing nothing) to offset (partially or totally) the costs of ‘doing something’would ever be realised. Productivity losses, reduced tax payments and increased welfare payments(estimated in a separate consultant’s report to be between £56 and 70 billion per year) could only beavoided if there are jobs available for and accepted by those whose health is to be improved underreduced social inequalities in health. Of course increased taxes and reduced welfare expenditure(approximately 40% of this estimated total ‘saving’) are simply transfer payments and represent changesin the distribution of command over resources, not a change in resources themselves. Moreover, those atthe greatest risk of poor health tend to be those with the lowest levels of skills. We might expect theseindividuals to be in those parts of the labor force usually characterised by excess supply. If better healthwas the answer to unemployment wouldn’t governments already have prioritized ‘health for all’?

Finally, if the England XI thinks that improvements in the health of part or all of the population willlead to reductions in health-care costs, they should check out Evans’ Health Care Income–Expenditureidentity (Evans, 1984). You only reduce health-care costs by closing hospitals and firing doctors – yes,they are dreaming that dream again. This financial sleight of hand is straight out of the Enron School ofEconomics.

THERE ARE DREAMS THAT CANNOT BE, AND THERE ARE STORMS WE CANNOTWEATHER

There is a distinct absence of evidence for the effectiveness of health interventions aimed at reducinginequalities in health (Arblaster et al., 1996; Culyer, 2009). There are many possibilities for improvingthe health of the poorest and sickest groups in society – the National Health Service did precisely that –but the ‘outcome’, in terms of social inequalities in health, was negative. This does not mean the NHSshould be abolished, but it does mean we cannot justify the NHS (or any of the policies presented by theEngland XI) by the impact on social inequalities.

Similarly, the England XI’s ambition (5 dream) of creating conditions for people to take controlover their own lives does not mean that social inequalities in health will be reduced. Individuals are nothealth maximizers and taking control might actually empower individuals to take rational decisions thatinvolve less health (where the other utility-bearing aspects of those actions compensate them for thedisutility of the expected reductions in health). Providing me with the means of controlling my own lifewill never get me jogging, eating spinach and nut roasts or giving up Boddingtons beer – even though Iknow that doing these things would likely improve my health. If you want me to be a health maximizer,or even to live and work in ways that might produce the health levels the England XI wish I had,waterboarding with its strong evidence base for inducing compliance, might be your only option! Thenotion that empowering people to be healthy will lead to them actually being healthy, until provenotherwise is extending the dream.

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NOW LIFE HAS KILLED THE DREAM I DREAMED

The problem of social inequalities in health in the UK and the recognition that the causes of theseinequalities are deeply engrained in broad social forces (living and working conditions) goes back atleast as far as Engels’ Condition of the Working Class in England published in 1845 and has been‘topical’ throughout the last 165 years with many reports including the work of among others Rowntree(1901), Beveridge (1942), Black et al. (1980) and Acheson et al. (1998). But like England’s attempt towin the football World Cup, changing the captain hasn’t led to any greater success. Noticeable by itsabsence in the England XI’s report is any consideration of the impact of proposed policies on healthinequalities. Why not extend the notion of Health Impact Assessment (HIA), which is concerned withmonitoring the impact of different public policies on the health of the population, to health inequalitiesimpact assessment (HIIA)? Could this be the Gini (coefficient) waiting to be let out of the bottle or acase of two ‘I’s being better than one?

Similarly the England XI do not consider examples of reductions in social inequalities in health overtime where this has been achieved (e.g. Cuba, Kerala). Instead, where international comparisons havebeen made (Black et al., 1980) these tend to have focussed on cross-section comparisons of socialinequalities in health as opposed to changes in the levels of social inequalities in health. Just as thecumbersome national managerial structure of the Football Association might explain England’s lack ofsuccess in football, could it be that structural factors in society are responsible for the persistent andgrowing social inequalities in health?

In a critical appraisal of the UK’s last inquiry on inequalities in health I concluded that ‘If policydevelopments are to be constrained by current social structures being viewed as sacrosanct, the pursuit ofreductions in inequalities in health is likely to (remain) a mystery’ (Birch 1999). Health economics hasboth the theoretical models (e.g. Grossman 1972) and the empirical frameworks (e.g. Van Doorslaer,Wagstaff and Rutten 1993) to understand the causes of social inequalities in health and to measure theimpact of policies on social inequalities in health. The report clearly missed out on using economicsexpertize to complement the other skills in the England XI. My fear is that unless we change the team, inanother 10–15 years the next government-working group on social inequalities in health will be reportingthe same findings on increasing inequalities and England will still be waiting to win the world cup.

REFERENCES

Acheson D, Barker D, Chambers J, Graham H, Marmot M, Whitehead M. 1998. Independent Inquiry IntoInequalities in Health: Report. The Stationery Office: London.

Arblaster L, Lambert M, Entwistle V, Forster M, Fullerton D, Sheldon T, Watt I. 1996. A systematic review of theeffectiveness of health service interventions aimed at reducing inequalities in health. Journal of Health ServicesResearch and Policy 1: 93–100.

Beveridge W. 1942. Social Insurance and Allied Services. Cmd 6440. Her Majesty’s Stationery Office: London.Birch S. 1999. The 39 steps: the mystery of health inequalities in the UK. Health Economics 8: 301–308.Birch S, Jerrett M, Eyles J. 2000. Heterogeneity in the determinants of health and illness: the example of

socioeconomic status and smoking. Social Science and Medicine 51: 307–317.Birch S, Jerrett M, Wilson K, Law M, Elliott S, Eyles J. 2005. Heterogeneities in the production of health: smoking,

health status and place. Health Policy 72/3: 301–310.Black D, Morris J, Smith C, Townsend P. 1980. Inequalities in Health: Report of a Research Working Group.

Department of Health and Social Security: London.Culyer A. 2009. Evidence, uncertainty and the policy pursuit of equity. Inaugural Conference of the Ontario

Research Chairs in Public Policy, University of Toronto, Toronto.Culyer A, Lomas J. 2006. Deliberative processes and evidence-informed decision making in health care – do they

work and how might we know. Evidence and Policy 2: 357–371.Davey Smith G, Shipley M. 1991. Confounding of occupation and smoking: its magnitude and consequences.

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Evans R. 1984. Strained Mercy: The Economics of Canadian Health Care. Butterworths: Toronto.Graham H. 1994. Gender and class as dimensions of smoking behaviour in Britain: insights from a survey of

mothers. Social Science and Medicine 38: 691–698.Grossman M. 1972. On the concept of health capital and the demand for heath. Journal of Political Economy 82:

223–255.Kooiker S, Christiansen T. 1995. Inequalities in health: the interaction of circumstances and health related

behaviour. Sociology of Health and Illness 17: 495–524.Oakley A. 1994. Who cares for health? Social relations, gender and the public health. Journal of Epidemiology and

Community Health 48: 427–434.Rowntree BS (ed.). 1901. Poverty: A Study of Town Life. Macmillan: London.Strategic review of health inequalities in England post 2010. 2010. Fair Society, Healthy Lives (The Marmot

Review). University College London: London.Van Doorslaer E, Wagstaff A, Rutten F (eds). 1993. Equity in the Finance and Delivery of Health Care: An

International Perspective. Oxford University Press: Oxford.

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