This week I’ve been thinking a lot about premature death. Not a particularly pleasant topic, granted, but one which Jeremy Hunt and the Department of Health seem to have recently woken up to.
Public Health England has just launched its Longer Lives project “dedicated to improving the nation’s health and wellbeing, and reducing health inequalities across the country [by making] England’s mortality data accessible to everyone.” The launch of this latest data project was headlined by the Department of Health as showing “local variation in avoidable death rates”. In response Jeremy Hunt tweeted of “shocking inequalities we can now see need addressing” and talked of a “postcode lottery” when it comes to public health.
So we have shocking health inequalities in England? Where you live affects your health? You don’t say! That’s what health inequalities are all about. As the European Portal for Action on Health Inequalities states “Health inequalities are preventable and unfair differences in health status between groups, populations or individuals. They exist because of unequal distributions of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to have access to the right treatments.”
Up here in Manchester (which has the dubious distinction of being at the very bottom of the shiny new premature mortality league tables) we have known all this for a long time. It’s hardly news to us that Mancunians find themselves at the sharp end of copping an untimely death thanks to cancer, stroke, heart, lung or liver disease, although admittedly Blackpudlians narrowly beat us in the last two categories. (Go Blackpool!).
More invisible in the debate, is that health inequalities do not just relate to the big killers listed above but also to mental health and a range of long-term conditions that might not quite kill you but can make lives very difficult indeed. As its Joint Strategic Needs Assessment makes clear, Manchester isn’t exactly blessed in these departments either.
For years public health professionals have pointed out the social determinants of health, many of which lie beyond the direct influence of health care. For example the Rainbow Model by Dahlgren and Whitehead illustrates this beautifully (in relation to mental health). When it comes to our health individual differences (lifestyle, age and hereditary factors) are outweighed by social and community influences, living and working conditions and the general socioeconomic, cultural and environmental context. Despite this public health promotion activities are usually targeted heavily at changing individuals’ lifestyles as well as screening for conditions based on age, hereditary factors.
So in theory recent moves to give local authorities more power to shape the public health agenda are welcome. This should enable councils to take a holistic approach that recognises the far greater impact of deprivation, unemployment, housing, transport and so on to our health and wellbeing.
But local authorities do not operate in a vacuum and what happens on a national level matters. Even at the level of ‘individual lifestyles’, some measures to tackle risk factors such as plain packaging for cigarettes or a minimum unit price for alcohol have to be taken by central government.
More importantly there are limits to what local authorities such as Manchester can do to tackle these social determinants. The North-South divide that strongly emerges from the data presented by Longer Lives has been identified by countless previous studies. It obviously cannot be addressed by Manchester City Council alone.
Local authority funding overall really makes a difference. Manchester received only £41 million for public health rather than our £51 million target allocation based on the government’s own formula. But it’s about far more than just about the cash directly doled out for public health -Local authorities cannot invest in prevention or take action to improve local infrastructure, housing, transport, etc. if they lack the necessary funds to do so. In our case, Manchester yet again has drawn the short straw. Manchester ranks fourth highest on the Index of Multiple Deprivation. We have also experienced some of the greatest cuts to our Local Government Grant overall since the election in 2010. In the first round of cuts, for instance, Manchester lost 10.9 per cent of its cash spending power whereas the best-off authority of Richmond Upon Thames lost only 0.6 per cent. This has led to countless cuts and reorganisations to our local services, which in turn will directly impact on people’s health and wellbeing. People with dementia in Manchester, for example, are just one group of the hardest hit.
Of course this is also true for most other local authorities with high levels of deprivation up and down the country. Indeed, an analysis of the distribution of cuts carried out by the Joseph Rowntree Foundation found that the overall impact of the distribution of cuts between different types of area and authority “appears to be very adverse indeed for more urban and deprived authorities and relatively modest for relatively affluent suburban areas.” Furthermore, as Graeme Henderson from IPPR North points out, “the coalition has changed the public health funding allocations for the next two years with some of the healthiest and wealthiest areas in the country having been allocated much more than some of the most deprived areas.”
I appreciate that Jeremy is "shocked". But I would much rather that he and his coalition colleagues took responsibility for the crucial role they rightly have to play in reducing health inequalities, rather than creating league tables of data to help them offload this onto local authorities or indeed on us poor, unhealthy, misbehaving punters who are also seemingly to blame big time for our unhealthy “lifestyle choices”. Because what Jeremy and Co are doing now is simply pointing the finger at everyone but themselves. This reeks of a neo-liberal agenda that negates the responsibility of the state. It shifts the blame to those who are disadvantaged and marginalised for the consequences of that disadvantage, and ultimately completely fails to tackle the real issues. With that in mind, I guess, I simply have to resign myself to probably dying much younger than, say, someone who lives in Jeremy’s constituency in South West Surrey. Ah well…