How and why does policy continue to fail to address inequalities in health? asks Professor James Nazroo.
A recent report on inequalities in health, commissioned by the British Academy, brought together responses to the question, “What one policy could make a difference if implemented at a local level?” The context was, of course, local government, which has taken responsibility for public health and, by implication, for dealing with inequalities in health.
As a contributor to the report, writing on ethnic inequalities in health, I felt an important opportunity had been missed. Not only does the focus on localism ignore where the power to redress inequalities in health actually lies – which is central government – but a focus on ‘one policy’ ignores the inter-connection of social process that determine inequalities. This inter-connectedness becomes particularly obvious when we consider the question of ethnicity.
Several inquiries since the Black Report have acknowledged that redressing inequalities in health requires a focus on the reduction of social and economic inequalities – the redistribution of resources. And a consideration of social and economic inequalities in relation to ethnicity shows the importance of addressing the complex interdependency of underlying processes.
Let us consider, for example, the ways in which ethnic identities are constructed by the powerful and the implications of this for how groups of people are racialised – that is, how their identities are fundamentally devalued. This then impacts on access to social and political resources, educational and economic marginalisation and the exploitation of some forms of migrant labour. One policy cannot be adequate to address these complex issues….
But if we were to opt for one policy it would have to be around something fundamental, perhaps the Runnymede Trust’s ambition to end racism in This Generation is the one. As Laia Bécares has argued, ‘racism is toxic for health’. However, such a fundamental ambition is not something that I would characterise as within the remit of local policy, even if it requires some local action.
Those who have the power to redress inequalities do not operate in a local government context. Indeed, the devolution of public health to local authorities should not be a means for central government to avoid responsibility for health inequalities. We could, and should, ask why such an important and fundamental issue appears to have been devolved to local responsibility, particularly when central government frames and sets local budgets and local policies.
My contribution to the British Academy Report began with a broad demand for ethnicity to no longer be marginalised in discussions of inequalities in health. It then attempted to focus on one dimension of redistribution that might lie within the power of local government – improving the employment conditions of public sector workers. My argument was that the public sector has the opportunity to provide a significant leadership role by setting standards regarding good, equitable, employment practices, and by ensuring subcontractors and independent contractors providing public services also meet these standards.
Such standard setting could cover employment rights, holidays, sick leave, training and study leave, maternity leave, job security, job flexibility, limits to unpaid overtime and management practices that promote autonomy and control at work. Changes like this would mostly benefit those in lower employment grades and more uncertain employment conditions. In addition, improvements in employment conditions could also include financial benefits, ensuring a more equitable distribution of salaries across employment grades and developing and protecting pension rights with the explicit intention of minimising inequalities in income post retirement.
The immediate and longer-term impact of an approach like this on the broader social determinants of health inequalities is likely to be significant. This is particularly so for ethnic minority groups, who are over-represented in public sector workforces. Importantly, this would impact on local job markets, meaning other employers would need to follow suit if they are to compete.
However, the context of the British Academy report meant that my recommendations did not get to the heart of the inequalities in social and economic resources that drive ethnic inequalities in health. For this we do need a lead from central government to curb, rather than ignore or promote, racism. But such leadership is missing, notwithstanding Theresa May’s expression of surprise at the continuation of anti-Semitism.
As I have asked elsewhere, when was the last time you heard an MP, let alone a minister, talk about ethnicity in terms of inequality? In mainstream policy discussion we appear to have moved into a policy discussion where ethnicity is no longer considered to be a driver of disadvantage. Rather, the focus is on ethnic identities that are, in the face of strong contrary evidence, claimed to encompass attitudes and behaviours that are not sufficiently British. The racialisation of ethnic minority identities, identifying identity as the problem, further undermines access to social, political and economic resources and actively promotes inequality.
What kind of political leadership denies those who speak different languages, observe different religions and have different family forms, a legitimate claim to British identity and consequent moral rights?
The views presented here are those of the author, and do not necessarily reflect those of other members of the Centre on Dynamics of Ethnicity (CoDE).