The current debate about health 'inequalities' is not especially helpful or informed. On the face of things we are presented with what sounds like irrefutable evidence that being born in a particular place will inflict a shorter lifespan on the poor child:
Men in the most deprived part of the population across England, dubbed the "bottom decile" by statisticians, are set to die before they reach 74 years old – almost a decade earlier than those in the top decile, who can expect to live until they are 83 years old. Women share a similar fate, with those born in the bottom decile expected to die by the time they are 79 years old, seven years earlier than the most affluent at 86.
The result - as with much of this 'inequality' debate - is a load of froth and bother all wrapped in political accusation. Yet these figures don't answer a simple question: what happens when the child born in a 'bottom decile' place moves to live in a 'top decile' place? Or indeed vice versa? Does this act result in the diminution of health inequality or does that act of moving wonderfully prolong or sadly shorten the life of the person?
The truth in all this is, of course, that most of this geographical difference results from the concentration of poverty rather than the effect of that place on health. No-one is disputing that there is a pretty close link between poverty (however you want to measure poverty) and poor health. But we should remember that people are not poor because they live on Bradford's Holme Wood estate, they live on that estate because they are poor. Indeed, it would be interesting to know how many of the children born to parents living on Holme Wood actually spend their entire life living there? My guess is that this will be a pretty small proportion of those children.
It's also important for us to note that this debate isn't about the distribution of health spending. After all, health spending is disproportionately directed to people who are in poor health. Mostly this means more is spent (over three-quarters of total spending) on old people but it also means more is spent on poor people simply because those poor people are more likely to be ill. Indeed, being in chronic poor health is a pretty good start on the road to poverty itself - there are plenty of people that are poor because they're ill or disabled rather than the other way round. This might not be a good thing, indeed it probably isn't, but it is a fact.
The problem with much of this debate - we're talking about health here but we could be discussing more general issues around deprivation - is that it assumes a static population when everything we know about poor communities is that their populations are not static. And we know something about movers too:
...groups most likely to move include younger age groups (16–34); private rented sector households; recent movers; large and single-person households; residents with higher qualifications (NVQ4 or above); males; and white residents
And those moving into deprived areas (this research is for New Deal for Communities areas - all in the 'bottom decile' of multiple deprivation):
...people moving in are more likely to be younger, white (but not British), or from a black and minority ethnic (BME) background, to live in a larger households and to be accommodated in the private rented sector
While not an absolute, the tendency is for the relatively successful to move out with their place being taken by a new generation of relatively poorer people. And somewhere around 10% of the population moves out each year.
What we fail to do in discussing deprivation is to make the distinction between things that are genuinely about the place and things that reflect the demographics of the place's population. By way of example, it's a good call to say that Bradford's tight, gardenless terraces will feature higher levels of road traffic accidents and conditions (asthma, bronchitis and even lung cancer) that link to poor air quality. But to suggest that this environment leads to higher rates of smoking, obesity or diabetes rather stretches the effect of place.
It makes a lot of sense to use geography to target resources better - the use of geodemographics and other modelling systems was a good idea when we proposed it to Bradford Health Authority back in 1990 and it's now an even better idea given our ability to make even better use of data modelling these days. But this still does not mean that people in Holme Wood are more likely to be in poor health because they live in Holme Wood.
The real debate shouldn't be about 'inequality' - after all we can fix that by poisoning the water supply in Ilkey! Rather we should be talking about poverty because we know that high levels of poverty result in more ill-health and lower average life expectancy. So the very best way to improve health outcomes - and we've seen this in the UK over the past three decades - is to reduce levels of poverty and increase levels of wealth and comfort. And, although I won't be thanked for saying this, capitalism is by far the most effective way to reduce poverty and increase wealth!