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There has always been an association between health and social class and, despite the welfare state and the improvement in health in all sections of societies over the years, this discrepancy remains. It applies to all aspects of health, including expectation of life, infant and maternal mortality and general level of health. Whilst the failure to close the social gap is a disgrace to some, others would claim that so long as these parameters are improving in all levels of society there is no cause for concern. A report on England from the Office for National Statistics shows that despite 67 years of the NHS, there remain marked differences in all parameters of health across the social classes.Women continue to live longer than men but the gap is closing.The situation, however, is complicated by the inequality between local areas which has increased over the period of two decades.
Males in the most deprived areas had a life expectancy 9.0 years shorter than males in the least deprived areas. They also spent a smaller proportion of their shorter lives in 'good' health (70.5% compared to 84.9%).
Females in the most deprived areas had a life expectancy 6.9 years shorter (when measured by the range) than females in the least deprived areas. They could also expect to spend 16.7 percentage points less of their lives in 'good' health (66.2% compared to 82.9%).
For men at age 65, life expectancy was highest In Kensington and Chelsea (21.6 years) and lowest in Manchester (15.9 years). For women at this age, life expectancy was highest in Camden (24.6 years) and again lowest in Manchester (18.8 years).[2, 3]
'Social class' is an over-simplified term which may encompass status, wealth, culture, background and employment. The relationship between class and ill health is not simple. There are a number of different influences on health, some of which include social class. This is demonstrated by multilevel analysis (a method of assessing health inequalities using several different factors) which shows health inequalities even between households living in the same street. In 1943, Sigerist, following the line of Virchow, wrote, "The task of medicine is to promote health, to prevent disease, to treat the sick when prevention is broken down and to rehabilitate the people after they have been cured. These are highly social functions and we must look at medicine as basically a social science."
The greatest influences on the improvement in health with longer expectancy of life, lower infant mortality, etc have been not so much medical discoveries as improved social conditions. One study in America found that, despite improvements in cancer detection and treatment, disparities in cancer mortality rates are chiefly related to race and social class.
In 1572 an Elizabethan Act made provision for the punishment of sturdy beggars and the relief of the impotent poor. A similar law followed in Scotland in 1574. In England, an Act of 1601 made provision for 'setting the poor on work'. This did not generally include accommodation but, in 1631, a workhouse was established in Abingdon and, in 1697, the Bristol Workhouse was established by private Act of Parliament. Scotland had 'houses of correction' established in the burghs, by an Act of 1672. Some people regarded all this as too liberal and, in 1834, Malthus argued that the population was increasing beyond the ability of the country to feed it. The Poor Law was seen as an encouragement to illegitimacy and this would lead in turn to mass starvation.
Edwin Chadwick published his 'General Report on the Sanitary Conditions of the Labouring Population of Great Britain' in 1842. This showed that the average age at death in Liverpool at that time was 35 for gentry and professionals but only 15 for labourers, mechanics and servants. In 1901, Seebohm Rowntree was able not only to trace in detail the sanitary defects of areas of York but he was able to compare the general mortality rates, infant mortality rates and heights and weights of children of different ages in three areas of York, distinguished according to the proportions living below his poverty line and compared with the servant keeping classes. The Rowntree family founded the famous chocolate company. They were, and still are, a Quaker family with a great social conscience as shown through the Joseph Rowntree Foundation and Trust.
The National Health Service
A Government document in 1944 stated "One of the fundamental principles of the National Health Service is to divorce the care of health from questions of personal means or other factors irrelevant to it."
Aneurin Bevan convinced the Treasury to fund the incredibly expensive package of the NHS in 1948, at a time of post-war austerity and massive nationalisation by the Labour government, with the argument that a national health service, free at the point of access, would so improve the health of the nation that the percentage of GDP spent on health would diminish. He was succeeded by Enoch Powell as Minister of Health after a general election. He found that there is no limit to the amount of money that could be spent on a national health service. It is a bottomless pit.
Causes of health inequalities
The relationship between social class and what are now called health inequalities is clear from simple observation. They affect not just adults but children too.The reason why they occur merits discussion.
- The question of post hoc ergo propter hoc (chicken or the egg) asks if it is the low social class that has led to the poor health or if poor health has led to a deterioration of social status. Studies of the Black Caribbean population in the UK patients found higher rates of psychopathology which were related to socio-economic disadvantage. However, most chronic diseases tend to present rather later in life, well into adulthood and after careers have been decided and the association with social class is not found. Hence, even looking at the question from the opposite direction and suggesting that the healthy will tend to rise through the social classes does not seem feasible.
- The material explanation blames poverty, poor housing conditions, lack of resources in health and educational provision as well as higher-risk occupations for the poor health of the lower social classes. Poverty is demonstrably bad for health. Life expectancy is low in poorer, less developed countries but the diseases that afflict the developed world tend to be related to obesity and tobacco and injudicious consumption of alcohol. Within the wealthy nations we find that they are most prevalent in their poorest regions and the lower social classes.
- The cultural explanation suggests that the lower social classes prefer less healthy lifestyles, eat more fatty foods, smoke more and exercise less than the middle and upper classes. They have less money to spend on a healthy diet, although this is probably rather less important than a lack of knowledge of what is a healthy diet. People who have been on their feet all day in shops or factories are less likely than office workers to seek activity in the evening, although their daily work has not been adequate to exercise the cardiorespiratory system. Despite the phrase as drunk as a lord, the association between binge drinking and social class has been readily noted and Frederich Engels wrote that "Drink is the bane of the working classes". Oscar Wilde inverted this to "Work is the bane of the drinking classes". Before the first report on Smoking and Health by the Royal College of Physicians, there was little difference in the incidence of smoking between social classes. Now there is a distinct gradation across social classes. It may seem reasonable to suggest that, when money is short, the first place for economies should be in the consumption of alcohol and tobacco but surveys have shown that in times of economic recession, there is no decline in demand. There is evidence that risk behaviours are unevenly distributed between the social classes and that this contributes to the health gradient. The link between health inequalities and IQ is controversial. The West of Scotland Twenty-07 cohort study found that IQ was the second highest risk factor for poor health in socially deprived communities.However, prospective trials of children who are now reaching middle age suggests that other factors such as disease risk and childhood adversity are at least as important.
- Social capital is a term used for how connected people are to their communities through work, family, membership of clubs, faith groups and political and social organisations. This has also been shown to have an impact on health. During the 1950s and 1960s a study of the Italian-American community of Roseto, Pennsylvania, where heart attacks were 50% less frequent than in surrounding communities, explained these differences by the greater social cohesion of this group. This concept has been confirmed by other workers. The idea that social isolation is bad for health is also supported by self-report studies that show housewives, the unemployed and the retired as reporting significantly poorer health than those who are employed.
The inverse care law
The failure of the NHS to provide a uniform level of care was summed up in a seminal paper by Julian Tudor Hart, called The Inverse Care Law. "In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and replacement staff. These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served."
The GP contract of 2004 included the Carr-Hill factor that was supposed to reward those who work in deprived areas. Far from reducing equality, this created a two-tier system in which some practices found themselves with considerably fewer resources than they had under the old system. The Department of Health's answer was to introduce a correction factor called the Minimum Practice Income Guarantee (MPIG).Intended to be a temporary expediency, it became a permanent feature of GMS funding. However, changes to the GP contract in 2013 signalled the phasing out of the MPIG between 2014 and 2021. The total sum of correction factor payments will be redistributed across all GMS practices. Practices who will lose significant resources as a result of this redistribution should have already been contacted by NHS England. They will be expected to put together a business plan to form the basis of negotiation with their local clinical commissioning group (CCG).
The Black Report
The report on Inequalities in Health Care was commissioned by Health Minister, David Ennals, in 1977 to address why the NHS had failed to reduce social inequalities in health. Despite the welfare state, there was evidence that social class difference with regard to health had widened. The expert group was chaired by Sir Douglas Black, former president of the Royal College of Physicians. The government changed and the release of the paper on August Bank Holiday Monday 1980 gave it almost iconic status as a government cover-up. The press release that accompanied it drew attention away from some of the more devastating findings. Scholars frequently refer back to it but, not only did the government of the day studiously ignore it, it has been considered 'off message' by the subsequent party of government. Patrick Jenkin, Minister at the time, was advised by civil servants to publish with the minimum of publicity because of the report's potentially huge implications for expenditure.
More details, including many tables and charts, are available via the Socialist Health Association website (see references below).
The Black Report showed that there had continued to be an improvement in health across all the classes during the first 35 years of the NHS but there was still a correlation between social class and infant mortality rates, life expectancy and inequalities in the use of medical services.
The following table shows death rates by sex and social (occupational) class in those aged 15-64 years in rates per 1,000 population. It relates to England and Wales (1971) and males refers to all males but females refers to married women only and classifies them by their husband's social class.
|Social (Occupational) Class||Males||Females||Ratio M/F|
|IIIn (Skilled non-manual)||5.80||2.76||1.96|
|IIIm (Skilled manual)||6.08||3.41||1.78|
|IV (Partly skilled)||7.96||4.27||1.87|
It shows that the death rate in that age group is 2.5 times as high in social class V as in class I and that the rate for men is almost twice that for women in all groups.
The following table shows birth weights of babies by father's social class and those with no father acknowledged, from Chamberlain 1975. It shows how going through the social classes down to where no father was acknowledged there was a progressive decline in babies over 3000 g and a progressive increase in babies under 2500 g.
|Social Class of Father||Birth Weight|
Percentage who weighed <2500 g
Percentage who weighed >3000 g
|I and II||4.5||81.0|
|IV and V||8.2||72.7|
|No father acknowledged||9.5||66.7|
The rate of usage of GP services increases with declining social class. This was attributed to more illness whilst they concluded that upper classes will consult over more minor problems. Primary care was seen as very important. Poor standards were identified in the areas of greatest need and primary care was identified as a major component in dealing with the problem.
Much more of both the problems and the perceived solutions are found on the website. They were unafraid to suggest changes in social policy such as a move towards the high taxation, high state dependency of the Scandinavian countries. Some of their suggestions have been addressed by changes to GP contracts but, generally, results are rather mixed. The uptake of vaccination and immunisation has improved greatly. The uptake for measles, mumps and rubella (MMR) remains a cause for concern but was improved by a catch-up campaign in 2013 for those aged 10-16. The uptake of cervical smears across all sections of society including all ethnic groups is quite astounding. The report also mentioned the benefits of fluoridation of water supplies for dental health. Currently, 6.1 million people receive fluorinated tap water in the UK and increasing numbers of local councils are initiating fluoridation schemes.
It may be tempting to think that the problems addressed by this report of over a quarter of a century ago are history; however, there is much evidence that many aspects are no better and that some are even worse.
The Acheson Report
In November 1998 a further report was produced, this time by Sir Donald Acheson, a former Chief Medical Officer. It found little cause for congratulation and also called for the issue of poverty to be addressed.[22, 23]
Addressing the problem
In the past, the major contributory factors to poor health were poor sanitation and infectious diseases. Today the problems relate to smoking, diet and accidents. Alcohol continues to contribute. Diet problems have changed from calorie deficiency to calorie excess.
Social class is not simply a matter of income. A plumber probably earns rather more than a priest but the latter is likely to have the healthier life. The difference in health between social classes is not simply a matter of disposable income.
The Coalition Government dismantled the previous administration's 'command and control' approach to public health and established local health and wellbeing boards (HWBs). They have continued to flourish under the incumbent Conservative Government. They are inclusive organisations involving all the key players in the local health economy, including local authorities, GP commissioners and providers of both primary and secondary care. They are charged with the responsibility to identify and address local public health needs, including health inequalities.
The Coalition's policy on public health was based largely on Fair Society, Healthy Lives (the Marmot Review). The Conservative Government has continued to build on this policy, the main principles of which were enshrined in the white paper Healthy Lives, Healthy People, as follows:
- It is important to build people's self-esteem, confidence and resilience right from infancy - with stronger support for early years. Self-esteem is the key to motivating individuals and addressing lifestyle factors that lead to health inequalities. There will be continued commitment to reduce child poverty, an increase in health visitors and a refocusing of the Sure Start scheme.
- Preventative services will be focused on delivering the best outcomes for citizens and the emphasis will be on local empowerment initiatives rather than top-down regulations ('the Big Society').
- Local government and local communities will be at the heart of improving health and well-being for their populations and tackling inequalities. There will be a new integrated public health service - Public Health England.
- The Department of Health will publish documents in 2011 on mental health, tobacco control, obesity, sexual health, pandemic flu preparedness, health protection and emergency preparedness and the wider determinants of health.
- The Marmot Review identified that people living in the poorest areas die on average seven years earlier than people living in richer areas and spend up to 17 more years living with poor health. They have higher rates of mental illness, of harm from alcohol, drugs and smoking, and of childhood emotional and behavioural problems. Although deaths from infections are becoming increasingly rare, tuberculosis, sexually transmitted diseases and pandemic flu remain continued threats.
- There will be new initiatives to tackle unemployment.
- Communities will be designed for 'active ageing' and sustainable growth, with protection of green spaces and encouragement of local food production.
- There will be working collaboratively with business and the voluntary sector through a 'Public Health Responsibility Deal' with five networks on food, alcohol, physical activity, health at work and behavioural change.
- The National Conversation on Health Inequalities - an opportunity for local authorities to start talking about health inequalities in their communities.
- Promotion of the Social Value Act - this 2013 legislation places a legal obligation on all public sector commissioners to consider how they could improve the economic, environmental and social well-being of their population through their procurement activities.
- Promoting good-quality jobs to reduce health inequalities - this includes adequate pay, protection from physical hazards and job security, all of which are less common among people in more disadvantaged socio-economic groups.
- Reducing social isolation - identification of who is at risk of social isolation and interventions that can minimise this.
- Improving health literacy - acquiring and maintaining the skills, knowledge, understanding and confidence needed to use health and social care information and services.
Further reading and references
Health in the post-2015 development agenda: need for a social determinants of health approach; World Health Organization
Brown T, Platt S, Amos A; Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review. Eur J Public Health. 2014 Aug24(4):551-6. doi: 10.1093/eurpub/cku065. Epub 2014 Jun 1.
Turley R, Saith R, Bhan N, et al; Slum upgrading strategies involving physical environment and infrastructure interventions and their effects on health and socio-economic outcomes. Cochrane Database Syst Rev. 2013 Jan 311:CD010067. doi: 10.1002/14651858.CD010067.pub2.
Inequality in healthy life expectancy at birth by national deciles of area deprivation: England, 2011 to 2013; Office for National Statistics
Life expectancy at birth and at age 65 by local areas in England and Wales, 2012 to 2014; Office for National Statistics
White C, Edgar G; Inequalities in healthy life expectancy by social class and area type: England, 2001-03. Health Stat Q. 2010 Spring(45):28-56.
Yang M, Eldridge S, Merlo J; Multilevel survival analysis of health inequalities in life expectancy. Int J Equity Health. 2009 Aug 238:31.
Black Report 1; Concepts of Health and Inequality Para 1.11, 1980.
Byers T; Two decades of declining cancer mortality: progress with disparity. Annu Rev Public Health. 2010 Apr 2131:121-32.
The Black Report of 1980; Socialist Health Association
A National Health Service; Socialist Health Association
Aneurin Bevan (1897-1960); National Service History
Farthing R; Health, inequality and child poverty in London. London J Prim Care (Abingdon). 2010 Jul3(1):2-4.
Morgan C, Kirkbride J, Hutchinson G, et al; Cumulative social disadvantage, ethnicity and first-episode psychosis: a case-control study. Psychol Med. 2008 Dec38(12):1701-15.
Batty GD, Deary IJ, Benzeval M, et al; Does IQ predict cardiovascular disease mortality as strongly as established risk factors? Comparison of effect estimates using the West of Scotland Twenty-07 cohort study. Eur J Cardiovasc Prev Rehabil. 2010 Feb17(1):24-7.
Kilgour AH, Starr JM, Whalley LJ; Associations between childhood intelligence (IQ), adult morbidity and mortality. Maturitas. 2010 Feb65(2):98-105. doi: 10.1016/j.maturitas.2009.09.021. Epub 2009 Oct 30.
Bruhn JG, Philips BU Jr, Wolf S; Lessons from Roseto 20 years later: a community study of heart disease. South Med J. 1982 May75(5):575-80.
Tudor Hart J; The Inverse Care Law. Lancet 27 Feb 1971. 1(7696):405-12
Guthrie B, McLean G, Sutton M; Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. Br J Gen Pract. 2006 Nov56(532):836-41.
General practice funding. Phasing out of MPIG - how it affects your practice; British Medical Association
Water fluoridation health monitoring; Public Health England, 2014
Olatunde O, White C, Smith MP; Life expectancy and disability-free life expectancy estimates for Middle Super Output Areas England, 1999-2003. Health Stat Q. 2010 Autumn
The Acheson report - up close; BBC News
Healthy Lives, Healthy People; HM Government, 2010 (archived content)
Addressing health inequalities at local level; Public Health England, 2015
Local action on health inequalities: practice resources; Public Health England, 2015
National Conversation on Health Inequalities; Public Health England, 2015