FeaturesBreaking the inequality cycle

Breaking the inequality cycle

With a growing crisis in the cost of living and little financial relief for the worst-off, the gap between the most and least healthy is likely to widen. Journalist Sarah Campbell looks at these inequalities and asks if they can ever improve.

As the chancellor, Rishi Sunak, stepped up to give his spring statement on 23 March, anti-poverty campaigners had their fingers crossed. With a cost of living crisis about to be intensified by soaring energy costs, war in Europe and inflation rising at its fastest rate in 30 years (Espiner, 2022), they were hoping for a financial lifeline for those struggling the most. In February around 30 organisations – including the Child Poverty Action Group (CPAG), the Joseph Rowntree Foundation and Citizens Advice – had called for a 6% increase to benefits in April to match inflation (CPAG, 2022). ‘Action is urgently needed to create an adequate welfare safety net […] Without this, the trend of the last decade of a widening gap in healthy life expectancy between richest and poorest is set to continue,’ said Jo Bibby, director of health at the Health Foundation. Had the chancellor heard them?

It would appear not. There was no mention of further additions to a previously announced increase of 3.1% to benefits. There was a 5p cut to fuel duty and an increase in the threshold for National Insurance contributions, as well as an increase in the Household Support Fund. But these measures will not help those at the ‘sharpest end of this crisis’, says Dave Innes, head of economics at the Joseph Rowntree Foundation. ‘The chancellor has abandoned many to the threat of destitution. Changes to National Insurance won’t help those who aren’t working or can’t work due to disability, illness or caring responsibilities, and exposes them to an increased risk of becoming destitute. This means they will face regularly going without absolute essentials such as food, energy and basic hygiene products.’

This will have a direct impact on people’s health. Financial inequality is one of the root causes of health inequality: research shows that the worse off people are in terms of debt, housing or poverty, the more difficult it is for them to move away from unhealthy behaviours (The King’s Fund, 2012). Janet Taylor, a public health nurse manager at South Eastern Health and Social Care Trust in Belfast and chair of the CPHVA Executive, regularly sees it first-hand. ‘Higher bills and greater outgoings are putting people just below the [poverty] line. They are having to make really difficult choices,’ she says.

‘If you have a young family, it’s expensive to buy fruit and vegetables and eat healthily. Not everybody has access to the cheaper stores – those in rural areas, for example. If you have got £5 and a family to feed, it’s easy to buy a bag of frozen chips and a pack of sausage rolls. At least it’ll fill them up.’

Why poverty is unhealthy

Janet’s observations are backed up with data. The Food Foundation found that healthier foods were three times more expensive per calorie than less healthy food (Food Foundation, 2020). ‘The poorest fifth of the population would have to spend an unrealistic 39% of their disposable income on food to afford the government-recommended healthy diet [Food Foundation, 2020],’ says Shona Goudie, policy research manager at the charity, referring to the government’s Eatwell Guide.

Food insecurity (being without reliable access to a sufficient quantity of affordable, nutritious food) is on the increase. Shona says that levels were already ‘concerningly high’ before the pandemic and have increased by over 40% since then.

The worse off people are in terms of debt, housing or poverty, the more difficult it is for them to move away from unhealthy behaviours

Between April and September 2021, foodbanks in the Trussell Trust’s UK-wide network distributed 5100 emergency food parcels a day – an increase of 11% compared to the same period in 2019 (Trussell Trust, 2021). Families with children were hit the hardest, with food parcels for children increasing at double the rate for adults. Shona adds: ‘Families being unable to afford to eat well or heat their homes will have a devastating effect on their health, both physically and mentally.’

Poverty and mental health problems also go hand-in-hand (Mental Health Foundation, 2016). ‘Anybody that has ever worried about money, or tried to make ends meet, knows that it has a direct impact on your mental health, on your stress levels, anxiety and coping mechanisms. It puts a lot of stress in the family,’ says Janet. She knows families who have fallen victim to loansharks, drug and alcohol abuse and marital break-up largely because of the stress of their financial situation.

‘It’s a vicious circle whenever people are just not coping. They’re not able to keep their environment as safe perhaps as they would like to or manage their children the way they [know they] can because they’re probably not sleeping with worry and stress.’

The wider context

Poverty, diet and mental health are just a few strands in an extremely complex web of factors affecting health inequality. Geography plays its part: a girl born today in the Orkney Islands, Brent or Wokingham can expect to be healthy into her seventies. Her contemporary born in Blackpool, Nottingham or North Ayrshire is likely to be plagued by ill health from the age of 55 (Health Foundation, 2022). The picture is similar, albeit slightly less extreme, for men.

Ethnicity is also a major factor, although in itself a complicated landscape. For example, The King’s Fund (2021) found that life expectancy at birth among people in Asian, Black African and Pakistani ethnic groups in England was higher than in white and mixed groups pre-pandemic. However, Covid-19 appears to have reversed this ‘mortality advantage’, although the reasons aren’t entirely clear.

Overall, however, the situation is getting worse. When Sir Michael Marmot published Fair society, healthy lives, the landmark study into health inequalities in England in 2010, he presumably was not expecting to follow it up 10 years later with a study that found signs that ‘society has stopped improving’ as increases in life expectancy have stalled. ‘The amount of time people spend in poor health has increased across England since 2010,’ was one of the key messages of the second report (Marmot et al, 2020).

While Sir Michael’s work focuses on England, its influence is such that its messages have been taken on board in the other UK nations. The Scottish Parliament acknowledges that much of the Marmot findings also apply to Scotland, with the dubious distinction of the ‘Glasgow effect’. In 2015, premature mortality (death before age 65) was 20% higher across Scotland in than in England and Wales, and is 30% higher in Glasgow than in similar UK cities such as Manchester, Liverpool and Belfast (Walsh et al, 2016). Marmot is referenced in health equalities policy and analysis in Wales (Welsh NHS Confederation, 2021) and Northern Ireland (Belfast Healthy Cities, 2020).

Hope for the future?

Rishi Sunak might not have heard pleas for immediate help for those in direst financial need, but are governments listening to the call to address health inequalities? Perhaps. The Welsh Government has an agreement with the World Health Organization Europe to increase equality in health by developing a health equity status report for Wales (WHO Europe, 2020). Wales is also trying out universal basic income – on a small, specific scale. A three-year pilot under which about 250 care-leavers will receive £19,200 a year will start in April, as highlighted in the last issue of Community Practitioner (Welsh Government, 2022). The governments in Scotland and Northern Ireland have put addressing health inequality central to health policy.

Poverty, diet and mental health are just a few strands in an extremely complex web of factors affecting health inequality

Investment in frontline public health staff such as community practitioners would improve the consistency of public health messaging and support for struggling families – and this has been acknowledged in parts of the UK. Janet points out that the piloting of multidisciplinary teams within NHS trusts in Northern Ireland has brought down caseloads of 0- to four-year-olds to an average of 250 per health visitor, meaning they can focus more on preventative work and make direct referrals within the team.

Tammy Boyce, senior research associate at the Institute of Health Equity at University College London, says: ‘It’s all about partnerships because these aren’t easy issues. But it’s also public health practitioners looking at the whole child or family and thinking about what is causing these issues – the social determinants of health. And often it’s possible to use the current system to address the problems – the solutions already exist.’ But it is much more difficult to find those solutions in a tick-box culture where community practitioners have such large caseloads they can barely cover the basics.

At UK government level there is now of course a whole department dedicated to addressing inequality: the Office for Health Improvement and Disparities (OHID), created out of pieces of Public Health England, which was dismantled last year. As it’s early days, it is hard to say what its impact will be. However, in a parliamentary debate in January several MPs expressed their concern that institutional expertise isn’t lost in the new set-up, and asked how OHID will work across government to address health inequalities (Twigg, 2022). The King’s Fund’s director of policy, Sally Warren, also identified cross-department working as key to OHID’s effectiveness (Warren, 2021). OHID’s role should become clearer following the publication of a health disparities white paper – although Sir Michael Marmot told senior public health professionals in March he has not been consulted about it (Kenyon, 2022).

The chancellor’s spring statement was a disappointment to anti-poverty campaigners, but there is increasing clamour that improving health must be a society-level effort, not something that can be changed solely by individuals. Nudging people into healthy choices is not working. ‘Take the traffic-light food-labelling system,’ says Tammy. ‘It helps individuals make choices but ultimately nothing’s really changed in terms of obesity levels. I’d prefer to see healthy choices made easier by making healthy food cheaper so people don’t have to use foodbanks.’

Increasing health inequalities are a situation of our own, human, making – and therefore one which experts agree can be reversed through society-wide action.

‘Only government can create the conditions for better health by improving the factors that lead to ill health in the first place,’ said Labour MP Peter Dowd during the January debate in Parliament. Whether the political will to do this exists remains to be seen.



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CPAG. (2022b) Child poverty facts and figures. See: https://cpag.org.uk/child-poverty/child-poverty-facts-and-figures (accessed 12 April 2022).

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Image credit | iStock


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