The mandate from the coalition government to the NHS Commissioning Board does mention inequalities five times, but the subject isn’t mentioned in any of the outcome areas and there is no hint of what the government expects the NHS to do to reduce the profound health inequalities that have been so well described and documented over the past decade. The recent abolition of the short-lived Cabinet Subcommittee on Public Health (due to a reported lack of interest from other government departments) does not bode well for the sort of cross-government working that is clearly necessary for the reduction of health inequalities.
In the foreword to his landmark 2010 report Fair Society – Healthy Lives, Michael Marmot wrote 'the more favoured people are, socially and economically, the better their health'. The report identified that children and young people should be the highest priority if we want to reduce health inequalities. There is little that the NHS can do by itself to reduce inequalities, but it could do what it has never done before and exert its societal authority as a collective organisation for which the English population has enormous respect.
Imagine the effect if all the paediatricians, GPs and health visitors campaigned actively in every constituency to reduce childhood obesity. 38 per cent of primary school children travel to school by car in England; a campaign to make it safe for every child who lives within half a mile of their primary school to walk or cycle instead could have major benefits. Not just for children of course – liveable towns and cities with walkable streets would deliver benefits for everyone, particularly in reducing the isolation of older people. It would also reduce the 13,000 deaths from air pollution every year. It is of course the poorest families that live in the worst environmental conditions so the benefits would particularly accrue to the most disadvantaged.
There is little doubt that the leading cause of health inequalities is smoking. We have done well to reduce smoking, but the rate has levelled off at about 20 per cent of the population. The key task now is to halt the recruitment of new smokers. Tobacco use is a paediatric epidemic, and if we can stop the tobacco industry gaining new customers then smoking will go into inevitable decline. NHS smoking cessation services won't give us our first smoke-free generation, but a gloves-off war on the tobacco industry might.
The health professions have led the fight against tobacco, rallied for seat belts and crash helmets and spoken out against alcohol abuse. It is but a step – admittedly a big one – for us to take up the cause of children and young people in bold and innovative ways. But we need new thinking if we are to reduce health inequalities. Where will this come from at a time when the NHS is being turned upside down by an unwanted, unneeded and deeply unpopular re-organisation? Can we add health advocacy to the duties expected of health professionals and a social conscience to the attributes of NHS trusts?
At the close of the foreword to his report Michael Marmot quoted a prescient line from Neruda's collection The Captain's Verses urging action 'against the organisation of misery'. If ever there is a time for collective action it is surely now.