HEALTH ECONOMICS

Health Econ. 8: 297–299 (1999)

INEQUALITIES IN HEALTH: AN EDITORIAL COMMENT

COMMENTARY ON THE ACHESON REPORT

ALAN WILLIAMS*Centre for Health Economics, Uni6ersity of York, York, UK

Among the many admirable features of this reportis the relegation of the NHS to a minor role inreduction of inequalities of health, symbolized byassigning it only nine pages at the end of thereport, compared with the 64 pages devoted ear-lier to Poverty, Income, Tax, Benefits, Education,Employment, Housing, Environment, Mobility,Transport, Pollution, Nutrition, Agriculture, Eth-nicity and Gender. A second admirable feature isthe vast amount of evidence that is assembled andcommented upon, drawing on research that hadbeen mostly conducted in the lean years wheninequalities were not high on the political agenda.A third admirable feature is the very straightfor-ward exposition of quite complex matters, so thatthe message, section by section, is always clear. Itwill be a useful source book.

But there are also some less admirable features.The central item in their terms of reference re-quired the members of the Inquiry ‘to identifypriority areas for future policy development,which scientific and expert evidence are likely tooffer opportunities for Government to developbeneficial, cost effective and affordable interven-tions to reduce health inequalities’. I will resist thetemptation to comment on the distinction drawnbetween ‘scientific’ and ‘expert’ evidence, for fearof distracting attention from the much more im-portant observation that they ditched the ‘costeffective and affordable’ bit of their remit, therebyrunning away from the central problem of prioritysetting. This is a serious dereliction, and I willcome back to it later.

From a scientific viewpoint the analysis gets offon the wrong foot as far as I am concerned by notdiscussing which concept of health should be the

focus of interest for this particular policy purpose.I have argued elsewhere [1] that it should bepeople’s whole lifetime experience of health. Sincepeople’s experience of health is a combination ofthe length of their lives and their health-relatedquality of life, we need to compare people’s qual-ity-adjusted life expectancy and seek to explainwhy it varies so much, and which of the causes weas a society are under some moral obligation toameliorate, and what if anything we can do aboutthem. The best measure we have of quality-ad-justed life expectancy comes from the health ex-pectancy literature, which plays a very very minorrole in the analysis presented in the report. Apartfrom the life expectancy data, nearly all of theevidence cited is cross-sectional rather than longi-tudinal, and no attempt is made to build uplifetime profiles of health from the data presented.And we are not presented with any estimates ofwhat each suggested measure would achieve asregards reducing inequalities in quality-adjustedlife expectancy. This leads to two serious weak-nesses: first, we get a series of snapshots of eachtype or source of inequality, based on piecemealevidence, with no framework within which tojudge its overall significance within a lifetime per-spective; and, second, we are left with the impres-sion that all inequalities are equallyinequitable . . . it seems that the facts are expectedto speak for themselves!

This points to the need for some philosophicaldiscussion as to possible reasons why we might beaverse to inequalities in health. Is it that they areintrinsically immoral? If so it is true that we needonly establish their existence to establish a causefor concern. But that would still leave us with the

* Correspondence to: Centre for Health Economics, University of York, York YO10 5DD, UK.

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task of considering whether they are all equallyimmoral. We might, however, take the view thatthey are not immoral per se, but their importanceflows from the notion that good health is a pre-requisite for people to flourish, and that differentsorts of inequality in health should, therefore, begraded in importance according to their adverseimpact upon people’s life plans. Good health maybe more important to some people than to others,and its importance may vary according to thestage of life that people are at. For instance,inequalities when people are bringing up youngchildren may be more important from a policyviewpoint than inequalities at other stages in life,such as old age. Behind this kind of discussion, isthere perhaps some notion that society shouldoffer everyone the opportunity to enjoy a ‘fairinnings’? Is our ‘entitlement’ the biblical ‘three-score years and ten’? Or, less ambitiously, is it (byimplication) 65 years, which is the age used in theofficial statistics as the norm from which to calcu-late ‘premature mortality’?

Surveys have consistently shown that the vastmajority of people (even old people) think thatwhen health gains are scarce the young shouldhave priority over the old. This view is almostcertainly based on the ‘fair innings’ notion, whichholds [2] that

‘. . . while it is always a misfortune to die when onewants to go on living, it is not a tragedy to die in oldage; but it is . . . both a tragedy and a misfortune tobe cut off prematurely’.

But suppose that society goes some way toensure that people get a more equal opportunityto enjoy a ‘fair innings’, and then some peoplethrow this opportunity away? Does society stillhave the same moral obligation to do somethingto keep things on an even keel? Are we under amoral obligation to offer smokers the same ‘fairinnings’ as non-smokers, by imposing sacrificeson non-smokers so as to reduce inequalities in thelifetime experience of health of the two groups?The way the report proceeds, this is the clearimplication since it nails its colours firmly to themast of reduction of inequalities as the goal, andnot simply making the worst off better (and let-ting the better off get better too). This impliesimposing sacrifices on the better off (irrespectiveof why they are better off) in order to concentrateresources on the worse off (irrespective of thereason why they are worse off). By shying awayfrom the resource implications, and from cost-ef-

fectiveness considerations, they were able tosweep these nasty implications about sacrificesunder the carpet, and play the role of the goodguys by listing lots of nice things to do withoutever calling on anyone to make any sacrificeswhatever.

So we are provided with no over-arching mea-sure of inequality in people’s lifetime experienceof health against which to test the relative magni-tudes, and no ethical framework within which toappraise the moral force of the recommendations.This leads to the words ‘inequality’ and ‘inequity’being used interchangeably throughout the report,thereby concealing the fact that there is a seriousquestion to be addressed as to whether all in-equalities are in fact equally inequitable.

I would like to take the chapter on genderinequalities as a case in point. It is well-knownthat women live longer than men (the differencesin life expectancy are roughly the same as thedifferences between the social classes). The differ-ences in health-related quality of life are rathermore problematic, but broadly speaking the menare worse off in early life, there are only minordifferences in the middle years, but women tendto be in poorer shape than men of the same ageamongst the elderly. The situation might becrudely summarized by saying that far fewer mensurvive into old age, but those that do are inbetter health than the much larger number ofwomen are. If one takes the crucial measure forequity purposes to be quality-adjusted life expec-tancy at birth, women still do better than men,though these differences are not as great as thedifferences in life expectancy. So in the chapter ongender inequalities one might expect the principalrecommendations to be things that would enablemen to live longer but leave women where theyare.

At an early stage the report makes it clear thatto reduce inequalities it is not sufficient simply tohelp the worse off. It is also necessary to ensurethat the better off are held back:

‘although the least well off may properly be givenpriority, if policies address only those at the bottomof the social hierarchy, inequalities will still exist’ (p.8).

But what do we find when it comes to genderinequalities? One recommendation that will re-duce the major accident rate in both men andwomen, and two that will increase the health-re-lated quality of life of women! Judging by the

Copyright © 1999 John Wiley & Sons, Ltd. Health Econ. 8: 297–299 (1999)

COMMENTARY ON THE ACHESON REPORT 299

data given in Figure 12 of the report (which hasthe wrong scale on the vertical axis), even if majoraccident rates were halved, the differential im-provement for males over females would only beabout 10 per 100000 for each year of age betweenabout 15 and 40, so in absolute terms it counts forless than would a 10% reduction in coronaryheart disease (Table 3 of the report), which wouldhelp men differentially far more. But what are theother two recommendations doing here? Recom-mendation 35 reads ‘We recommend policieswhich reduce psychosocial ill health in youngwomen in disadvantaged circumstances, particu-larly those caring for young children’. In detail,this recommendation goes on to concentrate onimproving social security benefits, nutritional andsocial service support for young mothers. Herethere seem to be mixed motives. One is a concernfor the welfare of children in poor households,which is not really a gender inequality issue at all.But there might be a ‘fair innings’ justification forsuch a measure if it could be shown that womenin disadvantaged circumstances have lower qual-ity-adjusted life expectancy than the average man(which is quite likely), but then so do men indisadvantaged circumstances, so it seems not tobe a gender-related equity argument at all. Itlooks as if the gender issue itself has not beenthought through properly. The third and finalrecommendation is ‘to reduce disability and ame-liorate its consequences in older women, particu-larly those living alone’. This surely has nojustification at all on gender equity grounds, forthe more successful such a policy is, the greaterwill be the inequalities in health between men andwomen! There is great confusion here. From theviewpoint of increasing the health of the commu-nity at large, this might well be a cost-effectivemeasure (who knows? . . . Since they did not ad-dress that issue, we are left in the dark on thatmatter), but as a means of improving the healthof men relatively to that of women it has noplace.

It is a great pity that there was not moreintellectual rigour imposed in trying to hold thisassembled evidence together and forcing it intosome framework that would enable us to judgethe relative significance of the various bits andpieces. At the end we are offered 11 pages ofrecommendations with no ordering of priorities.At the outset we are told that there are three areaswhich are regarded as crucial. They are:

� all policies likely to have an impact on healthshould be evaluated in terms of their impacton health inequalities;

� a high priority should be given to the health offamilies with children;

� further steps should be taken to reduce incomeinequalities and improve the living standardsof poor households.

The first is a procedural recommendation,which requires a prior specification of whichkinds of health inequality are important from apolicy viewpoint. Otherwise those evaluating theoutcomes of health care will have no idea of whatpersonal background characteristics of the af-fected people might be relevant for policy pur-poses. Does it extend to drug trials and otherevaluative work done by the MRC which mightthen be prioritized according to whether, if suc-cessful, it will help the old (a low priority in thiscontext, since they will already have had their ‘fairinnings’) or the vulnerable young (e.g. preventingteenage pregnancies or stopping pregnant womenfrom smoking)? As it stands this recommendationis too open-ended to be useful.

The second recommendation presumably is lim-ited to vulnerable families, because if all familieswith children are to be helped health inequalitieswill not be reduced. I suspect that here thinkinghas slipped back into considering anything thatmight improve population health overall, and in-equality reduction is not being kept in sharpenough focus. But perhaps it was meant to betaken jointly with the third recommendation,which certainly does offer a distant promise ofreducing inequalities in health. But it requires asharp and sustained increase in the progressivityof the tax and benefit system, and I do not detectany great enthusiasm for such moves on the partof New Labour. But that will be an interestingtest of their commitment to doing somethingabout the inequalities in lifetime experience ofhealth between rich and poor.

REFERENCES

1. Williams, A. Intergenerational equity: an explo-ration of the ‘fair innings’ argument. Health Eco-nomics 1997; 6: 117–132.

2. Harris, J. The 6alue of life. London: Routledge andKegan Paul, 1985, p. 91.

Copyright © 1999 John Wiley & Sons, Ltd. Health Econ. 8: 297–299 (1999)