Nigel Hawkes: The inequities of health equality

Behind the numbers

Health inequalities between rich and poor are widening, the Marmot Review concluded this week. Yet last October the Department of Health published data showing it was on track to achieve its targets for narrowing the gap in death rates for the two commonest killers, cancer and heart disease. Who's right?

Both are, bizarrely. It entirely depends how you define your target.

The way the Department of Health did it means that it's possible to proclaim success even as the relative gaps between rich and poor widen. Magic, if only you know how.

How it works is this. Death rates from common killers are falling. Since 1995-97 deaths from circulatory diseases have fallen from 141.3 per 100,000 to 74.8 per 100,000 in 2006-08. That's a fall of 47.1 per cent. But in the most disadvantaged part of the country the fall has been slower, at 45.3 per cent. Deaths are falling more slowly in poor areas than in England as a whole. In 1995-97, the gap was 25.9 per cent of the England average; by 2006-08, it was 30.2 per cent.

That's a widening gap, by most people's reckoning. But the measure the Government chose was not the "relative" gap but the "absolute" gap. And as death rates overall have almost halved over the period, this gap has narrowed. Mathematically, so long as deaths rates kept falling, the absolute gap was bound to narrow.

It's roughly like saying: "If we halved everybody's income tomorrow, the absolute gap in earnings between rich and poor would narrow." Of course it would.

As the Marmot Review points out, using absolute gaps between rates as a target is inappropriate. In both circulatory disease and cancer, it is the use of this target than enables the Department of Health to claim that gaps have narrowed when they haven't. Did they know this when it set the targets? They aren't daft, so it seems likely.

A major problem with any target for reducing inequality is that the levers used to achieve it act more effectively on the better-off than they do on the poor, so that inequalities are actually widened. A good example quoted by the Marmot Review is the Scottish target to cut smoking during pregnancy. It achieved results, but they were more than twice as good in affluent areas as they were in poorer ones. So the gap in smoking rates between rich and poor widened as a result of an initiative to narrow it.

Does this mean we're doomed to eternal inequalities? No. The middle classes are the first to respond to health messages, so campaigns have the perverse effect of widening gaps, to start with. But ultimately the gains begin to slow as the limits are reached. The wealthier will be the first to reach this plateau, and the poor will then begin to catch them up.

To put it another way: when there are no middle-class smokers left, anti-smoking campaigns will exert leverage only on the poor, and they will begin to narrow the gaps. Perhaps we should do more to celebrate the fact that health and life expectancy are improving, rather than lamenting the gaps that remain.