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An Applied Approach
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New public health governance arrangements under the coalition government have wide reaching implications for the delivery of health inequality interventions.

Through the framework of understanding health inequalities as a 'wicked problem' the book develops an applied approach to researching, understanding and addressing these by drawing on complexity theory. Case studies illuminate the text, illustrating and discussing the issues in real life terms and enabling public health, health promotion and health policy students at postgraduate level to fully understand and address the complexities of health inequalities.

The book is a valuable resource on current UK public health practice for academics, researchers and public health practitioners.

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In this challenging and original study, Wistow positions social policy within political economy and social contract debates.

Focusing on individual, intergenerational and societal outcomes related to health, place and social mobility in England, he draws on empirical evidence to show how the social contract produces longstanding, highly patterned and inequitable consequences in these areas. Globalisation and the political economy simultaneously contribute to the extent and nature of social problems and to social policy’s capacity to address them effectively.

Applying social contract theory, this book shows that society needs to take ownership of the outcomes it produces and critically interrogates the individualism inherent within the political economy.

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The chapter begins by considering what we mean by ‘health’ and by ‘inequalities’. When taken together health inequalities are often considered to be wicked problems – issues that are complex in terms of causal pathways, difficult to define and with no immediate solutions. They can pose challenges to traditional approaches to policy making and programme implementation. Furthermore, methodological approaches need to fit with the nature of the ‘problem’ i.e., responding to causal relationships in complex settings. Complexity theory provides one such approach. The chapter applies complexity theory to health inequalities by unpacking these concepts across the following dimensions: scales and boundaries; non-linear dynamics; self-organisation; and co-evolution. In so doing it is argued that we must avoid the temptation to control, isolate and reduce components of dynamic social systems to discrete elements and consider the interactions between histories, contexts and agency so as to be able to fully understand and respond to health inequalities.

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Health inequality outcomes in local systems reflect the design of services, interactions between agents and contextual attributes. This chapter outlines an approach to understanding health inequalities by adopting a whole systems approach that firstly focuses on different types of policy and practice, ways of working and types of interventions adopted in local health systems. Secondly, a range of contextual conditions, such as levels of deprivation, crime rates, demographics and educational attainment are outlined. Together these ‘conditions’ form a longlist of factors potentially influencing progress towards narrowing of health inequalities gaps. The chapter concludes with a discussion about how binary approaches to causation can be complex by reflecting the transition from one type of system to another e.g., the difference between a local authority area narrowing it’s health inequalities gap and one that is not.

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Health inequalities can be about when people die, about differential presence of particular pathologies and about limitations placed on the life they lead when they are living it. This chapter discusses the operationalisation (what are we measuring?), casing (for what are we measuring it?) and causality of health inequalities. The relationship between inequalities among aggregates in terms of complexes of causal to health states is not linear. The health consequences become much more severe for inequality at thresholds. Understanding health inequalities and determinants of these in terms of intersected complex systems at a variety of levels can help us delve into these and identify ways in which interventions may make a difference.

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This chapter provides a historical overview of policy and implementation in the period from the first statutory intervention in health in 1848 to the introduction of a universal health service in 1948 and more recent initiatives to address health inequalities under the Labour government of 1997 to 2010. It is argued that it is possible to see investing resources in immediate and universal access to medical services, the principal operating model for the NHS, as a diversion from health for all as opposed to health (medical) care for all. Indeed improvements in life expectancy have not been shared equally since the introduction of the NHS. Major reports on health inequalities (Black, Acheson and Marmot) have persistently emphasised the complex nature of health inequalities and the interrelationship of these with social and structural determinants. However, fundamental drivers of social inequality have not been prioritised following the publication of these reports. Furthermore, it is argued that medical imperialism has captured the terms of debate so that social determinants of health have received insufficient attention within the NHS given the restricted spending on prevention and the dominance of the medical model. This is described as a ‘category error’ given the nature of health inequalities.

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The chapter begins by summarising evidence about New Labour’s record on health inequalities and considers the implications of this given the shift from relatively high levels of public expenditure on services to a programme of austerity that framed much of the Coalition government’s agenda and policies that followed. This programme of austerity was not shared equally across the country with areas with higher levels of health inequalities tending to be most affected by cuts in spending. While the Coalition considered health inequalities to be a concern for government it did so whilst trying to refute that economic inequalities have social effects. The chapter then includes a detailed discussion of the Coalition’s health policy by exploring the Health and Social Care Act 2012; the Marmot Review; the transfer of public health responsibilities to local government; and the localism agenda. The potential implications for health inequalities are considered and the chapter concludes by arguing that immediate prospects for addressing health inequalities effectively seem to be more limited than under the previous New Labour administration.

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Health inequalities roots are embedded in the deep social structures of modern societies, which have implications for understanding and remedying them. Burawoy’s notions of ‘policy sociology’ (a concern with informing and promoting interventions) and ‘critical sociology’ (contextualising policies and interventions in terms of broader systemic and structural forces) have important implications for understanding and tackling such a complex and persistent social problem as health inequalities. In other words policy and practices and broader social determinants of health must both be addressed to narrow inequalities in health outcomes. This chapter introduces the concept of complex causation and applies this to the non-linear interactions that exist between multiple causes of health inequalities. By applying complexity theory to governance systems an epistemological approach is defined that helps to address the ontology of health inequalities by moving beyond traditional ‘public administration’ framings of the role of public health in tackling health inequalities.

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Not many things are as important to the quality of life as healthy and overall life expectancy. So why nearly 70 years after the creation of the NHS do we have wide variations in health outcomes that are related to peoples’ different and unequal positions in society? We might expect a universal free at the point of delivery health service to narrow these inequalities. However, this has not been the case. In addressing this topic it is necessary to view health inequalities as a ‘social problem’ – a problem that is created by, and exists within, society. In this respect health inequalities provide an important insight into the dynamics of contemporary societies, reflecting and shaping differences in life chances. Through the framework of understanding health inequalities as a ‘wicked problem’ the book develops an applied approach to researching, understanding and addressing these by drawing on complexity theory. Case studies illuminate the text, illustrating and discussing the issues in real life terms and enabling public health, health promotion and health policy students at postgraduate level to fully understand and address the complexities of health inequalities.

Restricted access
Author:

Not many things are as important to the quality of life as healthy and overall life expectancy. So why nearly 70 years after the creation of the NHS do we have wide variations in health outcomes that are related to peoples’ different and unequal positions in society? We might expect a universal free at the point of delivery health service to narrow these inequalities. However, this has not been the case. In addressing this topic it is necessary to view health inequalities as a ‘social problem’ – a problem that is created by, and exists within, society. In this respect health inequalities provide an important insight into the dynamics of contemporary societies, reflecting and shaping differences in life chances. Through the framework of understanding health inequalities as a ‘wicked problem’ the book develops an applied approach to researching, understanding and addressing these by drawing on complexity theory. Case studies illuminate the text, illustrating and discussing the issues in real life terms and enabling public health, health promotion and health policy students at postgraduate level to fully understand and address the complexities of health inequalities.

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