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  • Author or Editor: Jonathan Wistow x
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This chapter draws on case study research using qualitative comparative analysis (QCA) to develop understandings about what combinations of practice, policy and context work in addressing policy problems like health inequalities. Using set-theoretic and case-based methods such as QCA fits with assumptions about complex causal interdependencies. The method does not specify a single causal model. Instead causal pathways can be identified and investigated further. The chapter includes discussions about results of QCAs for cancers, cardiovascular disease and teenage conceptions in Spearhead areas and the combinations of conditions associated with narrowing or not narrowing health inequalities outcomes. The chapter concludes by focusing on implications for policy and practice. QCA is an exploratory method that demonstrates the same outcome can be reached in different ways, through interactions between policy, practice and context. These different pathways, or configurations of conditions, were used as a basis for developing set-theoretic knowledge and as a ‘tin-opener’ for researchers to work with local policy-makers and practitioners to gain further qualitative insight about the results.

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This concluding chapter draws the discussion to a close by considering three key issues that have arisen over the course of the book: the role of the NHS and others in tackling health inequalities; governance of health inequalities; and methodological and ideological considerations. Health is too often conceived of as an individual and medical issue in the way in which it is both resourced and understood. This is significant in terms of how public resources are prioritised between NHS, public health, local government and community and voluntary sectors. Furthermore, given the significance of multiple and non-linear causation for a wicked problem such as health inequalities it follows that we should take a research approach that concentrates on the complex interactions between people and settings. Finally, inequalities in health are profoundly important to peoples’ quality and extent of life – an equitable society is one in which good health is evenly distributed across social groups and does not follow a divisive social gradient. Consequently, there is scope to consider health as a key focus for redistribution and one that may help to move equality back up the ideological and political agenda.

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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.

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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.

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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.

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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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This chapter provides the theoretical framework for the book. In so doing, complexity theory is introduced as a means for integrating social policy, the political economy and social contract theory. Particular focus is paid to the social contract and its purpose in justifying the existence and legitimacy of the state. Different traditions in social contract theory are considered and an argument for adapting and applying an approach in the tradition of Rousseau is put forward, given his focus on the social contract as a lens to explore social outcomes and as a basis for pursuing greater equality as a foundation for these. The penultimate section of the chapter considers the role of social policy within the social contract and the political economy, questioning its impact in sustaining and legitimating the unequal and inequitable social outcomes produced through these. The final section outlines the structure of the book.

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The rise of neoliberalism in the late 1970s represents a movement to a new possibility space for the political economy and social contract and for the role and capacity of social policy to function within this. Neoliberalism has increased socioeconomic inequalities, sought to remove redundant (or spare) capacity from social systems, and does so from a narrow perspective of economic efficiency. Despite low growth and multiple crises in the economy, neoliberalism has remained remarkably resilient, which is due, in part, to the appeal of competitive and possessive individualism and arguments that the state, and state intervention, hold individual and collective progress back. Movement towards the market has led to increased fragmentation and decreased accountability within social policy delivery and governance, which (somewhat paradoxically) reduces the legitimacy of the state and the public sector. Untangling the web of influence of neoliberalism across the nexus of complex systems requires widespread, significant and sustained support, which is currently lacking.

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This chapter focuses on globalisation, the political economy and social policy, including how the wealthy capitalist economies have been complicit in strengthening the hand of capital. The global ‘race to the bottom’ has limited the ‘possibility space’ for social policy development through lowering corporation taxes, deregulating financial and labour markets and cutting welfare spending. Focusing on examples of climate change adaptation and the COVID-19 pandemic, the consequences of neoliberalism for social policy delivery are explored. Reduced capacity and increased fragmentation have impacted on the resilience of health and social care systems to external shocks. Neoliberalism and NPM have weakened the local state in England and, therefore, its role in shaping the social contract. In considering devolution, it is argued that greater powers and resources will enhance the responsiveness and accountability of the local state to its citizens and strengthen local democracy. Finally, Brexit is explored as a consequence of the social contract and a possible intensification of its trajectory.

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The UK is one of the most regionally unequal countries in the developed world. The centralisation of political, economic, cultural and policy systems in London has influenced the management of globalisation, deindustrialisation and neoliberalism within the UK, favouring the capital and embedding a spatial imbalance in the economy and society. Regional and local inequalities in, for example, education, health, labour markets and standards of living are consequences of the (mis)management of the political economy. Public ownership of land and housing have come under sustained attack and the large-scale privatisation of these has changed the role and capacity of the local (in particular) state and should be interpreted as fostering, and responding to, individualism within the social contract. All of these things stem from a selective and inconsistent application of the non-interventionist and market-oriented logic of financial capitalism.

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