Being poor is bad for your health and being ill is bad for your wealth

Babbling on about health inequality has become the latest obsession of the sort of Labour politician who rises to being a council leader or perhaps the shouty sort of backbench MP. This obsession leads to this sort of nonsense:

‘Shocking’ health inequality and poverty go hand-in-hand, meeting told

So says Susan Hinchcliffe, leader of Bradford Council as she comments on a report showing that people living in Ilkley - one of the wealthiest places in the North of England - live 21 years longer than people in Tong, one of the UK's most deprived communities. That both these places are in the Bradford metropolitan district is a quirk of political geography.

What's nonsense here is, of course, the idea that we should be shocked that poor people have less good health outcomes than rich people. This fact has been pretty much common knowledge since people first started thinking about health. So the solution isn't to, in some way, redirect resources from Ilkley to Tong (at a guess the per capita spending on healthcare in Tong is significantly higher already) but rather to reduce the poverty.

The second common misunderstanding here is that there is something about the place that means people are healthier - or for that matter richer. While place has some impact on health (air quality, for example) most health outcomes are entirely unrelated to where people are born or where they live. People in Tong are less healthy because they are poorer. And they live in these places because they have the affordable housing that poor people need.

And for some of the people in Tong, the reason they are poor is because they have poor health. Illness and disability can and does lead directly to reduced income. We can probably all think of someone we know who, because of their health, dropped out of a career or because of their disability never embarked on one. It's probably true that we could do more to reduce this effect but it's also true that we can only really resolve the poverty not the inequality.

So Bradford's "shocking" health inequality is entirely a consequence of Bradford's income inequality. And we don't fix this by making people in Ilkley poorer (or less healthy) but rather by making people in Tong richer. Indeed, we should stop using geography as a measure - especially given the degree to which otherwise intelligent people completely fail to grasp what local area statistics tell us - and should focus on people who are poor wherever they live.

Nationally we spend something like £6 billion on public health and a further £6 billion on various activities dubbed 'prevention'. If we were serious about improving health outcomes - and reducing that health inequality contingent on geographical concentrations of wealth or poverty - then we would shift most of this spending away from nannying people about booze, fags and burgers and spend it instead on programmes to reduce poverty. But I guess that doesn't fit the script.

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Soho is Britain's unhealthiest place? Jeffrey Bernard would be pleased!

Look how unhealthy it all is - drinking, eating. Shocking.

I don't know where the quote comes from but, as kids, we used to exclaim "give me temptation, brother" when confronted with something especially lovely - cream cakes, ice cream, warm pork pie. It would seem that the irresistible nature of these temptations - fast food, pubs and assorted other dens on iniquity - is the main reason for the UK's health inequalities:

Soho is the unhealthiest place to live in Britain...

I can hear a gentle chuckle from the grave of Jeffrey Bernard, legendary Soho denizen, at this shocking revelation - as Jeffrey put it:

"I've always been drawn to the things I was told not to do. Drink, sex. God! how I have loved sex and racing. They're against the rules and that's why I like them. I never liked anything that was good for me, like All-Bran and fresh air. I like the things that kill me."

So it is with Soho. But not, apparently, apparently with Great Torrington in north Devon. Probably because there's precious little to do (certainly in the category of "things that kill me") in Great Torrington. That being said, Torrington is a lovely little market town, especially if you like buying the crystal glasses in which to serve your champagne or malt whisky.

After Great Torrington, the remainder of the healthy places are in further flung parts of rural Scotland, not a thing to inspire folk who like a good time. Meanwhile, the really unhealthy places are mostly in central London. So how did the researchers arrived at the ranking:

Researchers analysed a range of lifestyle and environmental measures including levels of air pollution, access to amenities such as fast food outlets or pubs, and proximity to health services including GPs in addition to parks and recreational spaces.

It probably isn't so surprising that London fares poorly - it's densely populated, as a large city inevitably has poorer air quality than wide open Devon countryside, and - especially in the tourist magnet of the West End - is rammed full of pubs, bars and restaurants.

But why - given all the stuff about the 'heart of the community' and so forth - do these researchers cite the presence of pubs as an indicator of a place being 'unhealthy'? I'm guessing that the continued lie about drinking - any drinking - being bad for you sits at the heart of all this. The good news, despite the new puritans' best efforts to get them all closed, is that most people are still reasonable close to their nearest pub:

...on average, individuals in Great Britain are just as close to a pub or bar as they are to their nearest GP, 1.1 km [0.68 miles]

If we're talking about community then, frankly, having a pub people might visit once or twice a week is a darned sight more important than a GP surgery they might visit twice a year. And at least with pubs you can walk in when you need it rather than having to negotiate a complicated, unfriendly and unresponsive appointments system.

Our researchers (surprise, surprise - this is public health fussbucketry at its finest) also have an issue with gambling. They're shocked that most people live within "a short drive) - I'm surprised they're not agitated about folk having to drive there - of a betting shop.

What the research really shows is that things like fast food outlets, betting shops and pubs are more concentrated in densely populated urban areas. They also observe that lots of rural areas have a really lousy (on top of the deranged appointment systems and unfriendly hours beloved of GPs) access to primary heath care.

The premise for these researchers appears to be that the very presence of these bad things makes people ill. Unfortunately for our fussbuckets, either they don't make people ill or else people are resisting the temptations of booze, burgers and betting shops. The male life expectancy for Westminster (home to glorious Soho) residents is 81.4 years whereas those Great Torrington chaps down in North Devon peg it on average at a mere 79.4 years.

So it would seem that the effect of all that unhealthiness - pubs, bars, casinos, late night kebab shops and so forth - has precisely zero effect on the health of local residents. The research we're being sold here as "...an important tool for citizens and policymakers alike..." is pretty much useless as a guide to whether or not the environment in which people live is healthy (Shotley Gate, the little town across the estuary from Harwich gets fingered for unhealthiness which seems to reinforce the arbitrary nature of the model - I use this term loosely - adopted by the researchers).

And while we're about all this - central London lacks parks? Have these people never been there?

The green bits are parks. Massive parks. Soho is the redlined box.

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It's poverty that reduces life expectancy not being born in a poor place

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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!

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Merit, opportunity and the reduction of poverty in Bradford

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Yesterday I was at a 'development session' for Bradford's Health and Well-being Board and getting a bit irritated by the interminable mission creep (not to mention bucketloads of nannying fussbucketry). I appreciate that we have to 'tick everyone's box' in drawing up a five year strategy but there seems an almost wilful blindness to the big challenges facing Bradford's health economy. The first of these is a challenge everywhere - the rising cost of healthcare is outstripping society's ability to pay - but the second, while not unique to Bradford, is more specific. It is poverty.

And I say this in capital letters with flourishes and knobs on - the main reason for Bradford's poor health outcomes is poverty. It's not drinking. It's not smoking. It's not a big south Asian population. It's not obesity. It not illegal drug use. It's not road safety. It's not air quality. It is quite simply that being poor, always and everywhere, leads to a shorter and less healthy life.

Then I was corrected. Oh no, it's not poverty but something called "health inequality". Mostly, it seems because we have a strategy on combating "health inequality" but no strategy for reducing poverty. And this raises a very important issue by exposing again the conflation of poverty and inequality. With the result that we attend too much to enviously looking at how much richer, happier and healthier the residents of Burley-in-Wharfedale are compared with their counterparts in Barkerend.

What we should be doing is attending to the fact that people in Barkerend are poor not to the gap between their circumstances and the circumstances in Ilkley. But the conceit of the left (and of too many public services planners and managers) is the view that inequality and poverty are either inextricably linked or essentially the same thing. With the consequence that policy becomes about withdrawing from universal services in wealthy areas rather than the intelligent direction of resources to the alleviation of - with the end of eliminating - poverty.

This conceit - and its associated false dichotomy - is exemplified by this profile of Simon Willis who runs the Labour-supporting think tank, The Young Foundation:

"Let's say that we had a vigorous debate," he says. "The most important point Young made is that the opposite of inequality is not equality, it's fraternity … it's community and cooperation."

There we have our essential error about inequality. To say that the opposite of inequality is something other than equality is a deceit. It may be that fraternity, community and cooperation are more prevalent in a more equal society but it does not follow that equality leads to these things - nor do I see any supporting evidence. It also repeats the myth - a myth exposed time and time again only to be warmed over and reissued - that your riches are the cause of my poverty. But this time it is worse - Willis argues that the problem is 'meritocrats' because:

"They mistakenly think all their power and money and success is down to their own individual brilliance and hard work."

Again a familiar argument. Except that I've never met a successful person who didn't credit his or her success to a whole host of exogenous factors - from schools and parents through great colleagues to sheer good fortune.  Moreover we should consider what the alternative to meritocracy might be - presumably this is the 'fraternity' Willis alludes to as the opposite of equality. But isn't that a pretty stagnant society, a sort of land of 'meh'.

So I return to my earlier point. It is poverty that should challenge us not inequality. In the short-term part of the response to poverty is redistribution but over a longer period we need to alter the opportunities available to poor people, to allow them to play the meritocratic game along with everyone else. And these solutions are educational and economic - put bluntly better schools and better jobs. To say, as Willis is saying, that meritocracy is a problem is to deny the poor opportunity. Or rather to replace the chance to be independent, self-reliant and achieving with a sort of commune-like fraternal society.

This is just the intelligent articulation of the problem with community development - the idea that we can 'work with' communities from outside and that growing vegetables on roundabouts is somehow a substitute for education, skills and jobs. This is the world of the cuddly left where hugging the poor and saying 'there, there' is seen as a satisfactory response to the fact that they failed at school and haven't got a job. Or worse still giving them a hug and saying their problems are all the fault of those rich people in Ilkley (or bankers, or big business).

So back to Bradford and its health challenges. To make a difference we have to do a couple of things well - target interventions where they work best and recognise that improving the economic lot of people in Holme Wood or Barkerend is the best way to improve their health. For the targeting it's not about nannying because we know nannying doesn't work. Instead it's about real improvements - warmer homes, fewer chances to trip and fall, more pedestrianised areas, support for self-employment, training in today's skills and better outcomes at school. But this wouldn't suit The Young Foundation because what we're saying to those people is that they have skill, talent - genius even - and that we're going to release it, to allow them to achieve. Not from entitlement but from merit.

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Note on the causes of health inequality...

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This is from the ONS statistical bulletin entitled "Life Expectancy at Birth and at Age 65 by Local Areas in the United Kingdom, 2006-08 to 2010-12". It talks about possible reasons for health inequality - including this one:

One factor that has received less attention is the selective migration of healthy individuals from poorer health areas into better health areas or vice-versa. This type of migration has been shown to play a significant role in increasing or decreasing location-specific illness and mortality rates, which then consequently impact on life expectancy figures. Norman, Boyle and Rees (2005) demonstrated that the largest absolute flow within England and Wales between 1971 and 1991 was of relatively healthy people moving from more deprived into less deprived areas. The impact of this migration was to raise ill-health and mortality rates where these people originated from and lower them in the destination areas. The authors also noted that the benefit to less deprived areas was reinforced by a significant group of people in poor health who moved from less to more deprived locations.

Migration explains a lot of the variation it seems. So area-based approaches to reducing 'health inequality' may be addressing entirely the wrong target problem.

H/T Tim W