I have details of a new publication from the Office of Health Economics
ehich may be of interest

David

LSE Health and Social Care




Ohe publication briefing, Jan 2001 - Why Care about inequality - A J Oliver
Price £7.50 - Contact Liz Aulsford [log in to unmask] to purchase a copy

MAIN POINTS

*       With the election of the Labour government in 1997, the issue of
health inequality took a more prominent role in public policy debate.  The
government's commitment to this issue soon became obvious, with its
publication in 1998 of a review of health inequalities - in the Acheson
Report - and of the consultation paper Our Healthier Nation, one of whose
two key objectives is to improve the health of the worst-off in society and
narrow the health gap.

*       In this monograph for the Office of Health Economics, Adam Oliver
looks at health inequalities in the UK from a health economics perspective.
He presents evidence on health inequalities in the UK and outlines the main
arguments that have been put forward to explain the differences in health
across social class.  He goes on to explain why health inequality should be
seen as a problem by everyone in society, and not just by those who have the
worst health.  He then takes a closer look at whether inequalities in health
across all types of groups - for example, those defined by education, race,
gender or lifestyles, as well as income and social class - are inequitable,
and discusses definitions of equity in health.

*       Adam Oliver gives a critical appraisal of the Acheson Report.  Many
of that Report's 39 recommendations would improve health levels in the UK
but would not necessarily reduce health inequalities.  For example, smoking
cessation policies will, if successful, reduce illness and premature death
but may benefit the better off as much as, or more than, the poorest.

*       Secondly, the Acheson Report makes no attempt to prioritise its
numerous recommendations.  It provides no guide to which policies warrant
the greatest commitment of resources.  This is a serious failing and one
which health economists are equipped to help rectify by focusing their
efforts on evaluating the cost-effectiveness of different options for
reducing health inequalities.

SUMMARY

Health inequalities in the UK

For many decades there has been a general improvement in the average health
status of most groups of people within the UK.  But at the same time there
is evidence that inequalities in health have been increasing across social
classes, as shown by the 1980 Black Report and 1998 Acheson Report.

Causes

The absolute income hypothesis attributes health status principally to the
level of the individual's income: the higher are average incomes in the UK
the healthier we should all be on average.  The relative income hypothesis,
however, attributes the major role to the individual's income relative to
other people's: for any given average level of income, the more equally it
is distributed the higher will be the average standard of health.  Both
these hypotheses have been advanced as partial explanations for the health
inequalities across social class and both would seemingly prescribe
narrowing income differentials in order to reduce health inequalities.

Why care about health inequalities?

Although health inequalities in the UK appear to be wide, and perhaps
widening, are they really a cause for concern?  Rawlsian theory argues that
if we are placed behind a 'veil of ignorance' and hence do not know who we
are going to become - i.e. we could become a millionaire or homeless person
- then, a priori, we would wish to make the position of the worst off as
good as possible in case we were to find ourselves in that position.
Following this line of reasoning, wide and/or increasing health inequalities
are obviously unjust.

The Acheson Report

Soon after being elected to office in 1997, the Labour government
commissioned the Acheson Report, which reviewed the available evidence on
health inequalities, and made 39 policy recommendations on how they might be
addressed.  However, The Acheson Report did not consider the definition of
health, the extent to which health inequalities are inequitable, or the
importance of the different definitions of health inequality.  Adam Oliver
argues that:

*       lifetime health, rather than health status at a specific point in
time, should be the focus of interest; 

*       significant inequalities irrespective of where they occur are
inequitable; 

*       inequalities in health status rather than inequalities in health
care access or utilisation should be addressed. 

The Acheson Report's policy recommendations should have focussed more
sharply on reducing health inequalities rather than improving general
population health.  However, the Report reviewed and drew inferences from a
vast literature and so can be used as a solid starting point for identifying
the best ways of reducing health inequalities in the UK. One way to carry
forward the work of the Acheson inquiry team would be to determine which of
their recommendations have a very clear intuitive basis in reducing health
inequalities, and to gather the necessary evidence to prioritise these
recommendations according to their cost-effectiveness in achieving that. 

Priorities

Prioritising recommendations according to their cost-effectiveness would
help policy makers determine which recommendations offer worthwhile uses of
scarce resources.  Health economists can contribute expertise and advice
concerning the methods to use when undertaking such evaluation.  Part of
their contribution could involve helping to determine and develop
appropriate outcome measures.  In this monograph, equity-weighted QALYs
(quality adjusted life years) are proposed for consideration, though they
should be treated with care and with a view that methodological advancements
are necessary, as the validity of both equity weights and QALY measurement
techniques are still subject to much uncertainty.

Health economists have much to learn from the inequalities debate.  More
collaboration between health economists and other specialists in the area of
health inequalities would improve understanding of the fundamental causes of
health and inequalities in health that transcend health care.

Conclusions

Significant progress towards reducing unjustifiable health inequalities
ultimately lies in the hands of the government.  The current government has
been treating health inequalities as a cause of concern, and has done much
to raise the profile of the debate.  However, reducing the wide health
inequalities in the UK is a major task that will require a more concerted
effort than hitherto to show significant effect, even in the long term.  On
a health economic level, the potential contribution of economic evaluation
is highlighted in this monograph.  However, income redistribution policies
are likely to play a crucial role if health inequalities are ever to be
effectively and significantly addressed.  Whether the current and future
governments are willing to exert the necessary effort remains to be seen.