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Why aren't people more exercised about health inequalities?
'Social determinants' like housing and wealth have a huge impact on health outcomes, and poor health in turn leads to worse economic outcomes. Why is the British public not more concerned about this?
In January 2022, we ran an online event featuring Sir Michael Marmot and a range of other health experts to discuss why it is more urgent than ever that we tackle inequalities in order to improve health, why more progress has not been made in the last decade, and how we can rectify this failure.
During the discussion, Jo Bibby at the Health Foundation argued that the reason for limited progress on tackling health inequalities, despite all the evidence, is public understanding and attitudes. If health inequality isn't a public priority, it won't be a priority for government. We don't communicate or frame the issues well enough. As a result most people don't think beyond the role of the NHS or individual lifestyle choices.
Chris Thomas at the Institute for Public Policy Research referenced an IPPR report arguing that we are not making enough ‘totemic’ policy asks that can cut through to the public and increase pressure on politicians to act.
Last week, Chris and his colleagues at IPPR published the first report (twitter summary) of the Commission on Health and Prosperity, which turns the camera in the opposite direction, analysing longitudinal data to show that poor health (levels of which are on the rise in the UK) are associated with big drops in annual income and risks of leaving employment. Good health is “a crucial determinant of our economic prospects, both at an individual and a national level”, just as socio-economic factors are determinants of our health outcomes.
Attitudinal research in the UK in recent years (usefully summarised here by the Health Foundation) has shown two things:
A lot of people are not aware of the extent of health inequalities between people of different socio-economic status, ethnicity, gender and so on (and between regions), or of the causal links (in both directions) between ill health and ‘ill wealth’
Many people (especially those who tend towards more individualistic and meritocratic views about society) think that the main factors influencing someone’s health are their individual behaviour and their access to healthcare services, rather than socio-economic factors such as poverty, housing and so on, which is contradicted by reams of evidence about the significance of wider determinants of health
As an evidence review of attitudes to inequalities by the KCL Policy Institute sets out, the roughly one in three people who think in more ‘structural’ terms do generally believe that people with money are a lot better able to live healthy lives. However, the same number of people think in more individualistic ways and place more emphasis on personal responsibility. Moreover, across the population as a whole, people are in general less concerned about health inequalities than about regional and income inequalities. (This also has an impact on views about the provision of NHS services; the King’s Fund found in last year’s British Social Attitudes survey that few people see improving the health of the most disadvantaged as a priority for the NHS.)
Many of the policies that are needed to reverse the vicious cycle of ill health and ill wealth are already popular with the public, such as the list provided by IPPR (e.g. tackling the poor nutrition and obesity epidemic, introducing higher workplace and jobs standards, and improving early years and education services), or the policy priorities that each of our event panellists outlined to address health inequalities if they were to become Prime Minister (e.g. eliminating child poverty and investing more in social housing). So you could argue that we don’t need to raise public awareness of the vicious cycle, or to change minds about the causes of health inequalities.
But slow progress to date suggests otherwise. Shifting public attitudes about the links between health and wealth is crucial, and must be done alongside securing greater state investment, reforming institutions and making health a national ‘mission’ in government, as IPPR have recommended. We must continue to find ways to change hearts and minds.