The UK Government’s intention to reduce inequalities through the Levelling Up White Paper and forthcoming Health Disparities White Paper is welcome, and comes at a critical time. Currently people in the poorest areas of the UK die earlier than those in richer areas as health is strongly influenced by the social, economic and environmental conditions we live in. All risk factors – smoking, poor diet, and harmful alcohol use – are impacted by socioeconomic factors. 1 In England, childhood obesity is rising and the gap in prevalence is widening between the least and most deprived, 2 31% of households with someone who smokes fall below the poverty line3 and high-risk drinking* prevalence rose by 64% in the lower socioeconomic groups during the first lockdown.4 Furthermore, smoking is estimated to cost society as a whole £17 billion a year, £2.4 billion of which falls to the NHS.5
The impact these risk factors have is stark, and the link to health inequalities is well documented. For example, children living in the most deprived areas in England are more than twice as likely to be obese than children living in the least deprived areas.2 These preventable factors increase the risk of certain cancers, type 2 diabetes, lung and heart conditions, musculoskeletal conditions and poor mental health. Ultimately, this means if you are in a poorer household, you are more likely to have a shorter life and spend more time in poor health. We also know that factors such as ethnicity, age, gender identity, sexual orientation and disability have a cross cutting impact on health and underpin health inequalities. This needs to change, starting with this White Paper.
The UK Government is right to set ambitious targets to reduce preventable risk factors and transform lives, such as the recent commitment in the Levelling Up White Paper to increase Healthy Life Expectancy by 5 years by 2035. 6 But Health Foundation analysis indicates it would take almost 200 years to reach 5 years of improvement.7 Smoking – which is responsible for half the difference in life expectancy between the lowest and highest income groups in England8 – is a prime example of how action to tackle leading risk factors for inequalities and preventable disease can also help reach other Government targets on Healthy Life Expectancy. But according to Cancer Research UK analysis, we are not on track to deliver the Smokefree 2030 ambition until 2037, and the most deprived group won’t reach this target until the mid-2040s.9
Population-wide measures are required to level up health, and have successfully led to change in the past. The Government’s approach to addressing these risk factors is dominated by interventions aimed at individuals. However, this is reliant on individual agency and resource which risks deepening inequalities.1 Population-level interventions, alongside targeted support for those most in need are the most effective and equitable. The Soft Drinks Industry Levy, 10,11 Tobacco and Related Products Regulation, 12 and Minimum Unit Pricing of alcohol in Scotland 13,14,15 have all led to widespread change. If the UK Government are serious about tackling health inequalitiesit must introduce bold populationlevel interventions like these that are less reliant on individual resource, and instead aim to alter the environments in which people live. For smoking, the recent independent review by Dr Javed Khan provides a clear roadmap for the Government to implement.16 These recommendations must be considered, alongside equally bold measures for other risk factors if we are going to level up health * High-risk drinking defined by an Alcohol Use Disorders Identification Test – consumption (AUDIT-C) score ≥5 July 2022 and wealth. These population-wide measures should be implemented alongside additional targeted support for individuals and groups most at risk.
Long term cross-government action to tackle the root causes of ill health, including poverty, housing, and structural inequalities based on demographic factors such as ethnicity, is needed if the Health Disparities White Paper is going to truly address the risk factors strongly linked to health inequalities. For the White Paper to be a success, population-wide and targeted measures must be underpinned by a cross-government strategy to reduce health inequalities that considers the role of every department and every available policy lever in tackling health inequalities.
To be successful the Health Disparities White Paper will need ambitious measures that are backed up by sustainable and sufficient funding and adequate workforce. Public health funding is critical for improving health and reducing inequalities, yet local authorities in England have experienced a sustained programme of cuts in recent years, which severely compromises their ability to provide and deliver the vital functions and services that prevent ill health – such as stop smoking services and weight management programmes 17 – despite them being among the most cost-effective interventions available.18 The Health Foundation has calculated that the public health grant was cut by 24% in realterms between 2015/16 and 2021/22. This is equivalent to almost £1 billion reduction in total. These funding cuts have also been greatest in more deprived local authorities19 which risks exacerbating existing health inequalities. It is essential that public health is given the funding it requires so that vital services can be provided to those that need them most.
As the cost of living continues to rise and this has a greater impact on those most in need, the Health Disparities White Paper presents an opportunity for the UK Government to hold fast on their narrative that prevention is better than a cure,20 and invest to deliver against that welcome narrative. Prioritising prevention will help to improve the health of the nation, protect the NHS, and allow more people to live longer, healthier lives.
