Social inequality in health

Differences in health outcomes dependent on social background,

ethnicity, sexuality, gender, age
Despite the fact that NHS is free for all at point of need
Healthcare systems not about health. They are about managing
disease
Tend to access healthcare system once already quite ill/ developed
diseases
ITU = 1150 bed
Public health doctors not working in hospitals- now in council, left
PCT
Not a failure of healthcare system, however not about prevention
nor about different health outcomes
Social inequalities do not reflect the biological differences and
therefore not inevitable or unavoidable.
Social inequalities stem from structured social divisions that
exist within societies across history and cultures.
Investigating socio-economic class to determine Life chances for
social groups e.g in education, work, health outcomes.
Intelligence is a social construct
The socio-economic model of health
Adopts the broad position that social inequalities in health
reflect differential risk exposure across the lifespan.
This relative health risk is primarily associated with an
individuals socioeconomic class position.
Model of the social determinants of health
Poor health outcomes have more variables

Relative well-being, mortality and morbidity

Social structure- where you live, holidays, schools, economic

standing
Social environment - play facilities, sports
Health behaviour- smoking, drinking, exercise, stress can lead to
poor health behaviour etc
Stress levels at work - dependent on social background?
Stress has an impact on immune response - pschyoneuroimmunity?
Things in social life impacts on the immune response. Not isolated
within the individual, dynamic between environment and individual.
Social class- access to resources, money, occupation
Can be measured in a variety of ways with each method
reflecting a different theoretical position
RGOC based on relative status of occupation
Registrar-Generals Occupational Classification'
(as utilised throughout 20th century up until 2000)
1 Professional i.e doctors, lawyers, higher managers
2 Intermediate non-manual i.e nurses, middle managers
3 Junior non-manual i.e secretary, technician
3b Skilled manual
i.e carpenters, electricians etc
4 Semi-skilled manual i.e postman, farm worker
5 Unskilled manual i.e hospital porter, cleaner, labourer
This data has been collated for a while. Some of the jobs are
relatively old fashioned and excluded women.
Survey went through the man of the household. Their occupation
determined the social class of the family.
However people tend to mix with people of the same social class
and grouping.
The official social classification measures ( the NS SEC) is now based
on occupation, but this is assessed in relation to skill levels but on
employment conditions and relations.

This is a benign way of measuring social class.

School get extra money when many students come from group 8?
Similar with universities allowing access to lower socioeconomic
classes.
Persistent of health inequalities
Always existed.
Rich lived longer than the poor except during wars, infectious
disease. Rich cannot escape this. - non discriminatory
disease.
A post-war assumption that welfare state (NHS) would
eradicate poverty and inequity (note difference between
concepts of inequity and inequality).
It was naively assumed that meeting health care needs would
eliminate differences in health outcomes.
1919 Spanish Flu
SMR - standardised mortality rate

new classification halfway through the graph

social inequality widened despite the introduction of the welfare
state.
1930s - 3million people unemployed
Rationed diet meant health chances were similar during the war
If death rate were based on genetics, the levels would not change
within 40 years. The changes are therefore environmental.
In 1970s, the official view was that poor health resulted from
individual health behaviour.
The Black Report (1980) argued that it was primarily material
circumstances that were the main cause of social
inequalities in health. E.g income and life chances.

Poor health is not simply about poverty; it is in fact about many

different factors

Doct
ors are actually in social class three. Largest gap within the 1990s,
despite having an ethical healthcare system.
The findings from the Black report explained that inequalities in
health were the result of:
1. Artefact
2. Social/health selection

3. Behavioural/cultural factors
4. Material factors - i.e income, housing, education etc
The current literature shows general agreement about a
correlation between income inequality and health/social
problems.
There is less agreement about whether income inequality causes
health and social problems independently of other factors,
but some rigorous studies have found evidence of this.
The independent effect of income inequality on health problems
shown in some studies looks small in statistical terms. But these
studies cover whole populations, and hence a significant number of
lives.
Anxiety about status might explain income inequalitys effect
on health problems. If so, inequality is harmful because it places
people in a hierarchy which increases competition for status,
causing stress and leading to poor health and other negative
outcomes (Rowlingson:2011)
Summary of research findings
The social and material context of social inequalities
structures health outcomes.
Health risks associated with social disadvantage cluster
together and accumulate over time / longitudinally.
Inequalities in health should be seen as manifested across a
social gradient rather than being an outcome of poverty
alone.
Today
Following the implementation of the last Labour governments
reduction in health inequalities policy (introduced in 1999)
there were improvements in the mortality rates of all social
classes between 2001 and 2008.
However, when measured on an absolute scale, the gap between
the most and least socially advantaged had not substantially
changed.
And, when using relative measures of inequality, the results
indicate that inequality between managers and manual occupations
actually increased in this period.
In 2001, a worker in a routine or manual occupation was
twice as likely to die before the age of 65 than his
manager, but in 2008 that ratio had risen to 2.3 times
(ONS:2010).
As an example:
The mortality rate for the Routine class (NS-SEC class 7) is
500 deaths per 100,000 person years, and the mortality rate
for the Higher managerial and professional class (NS-SEC
class 1) is 100 deaths per 100,000 years.

If the rates change to 450 deaths and 75 deaths respectively,

then the gap between the most and least advantaged classes
shifts from 400 in the first instance (500100) to 375 in the
second instance (45075).
This implies that the gap in inequality has been reduced in
terms of the absolute number of deaths involved.
However, the deaths in the Routine class are five times as
high (500/100) as those in the more advantaged class in the
first case, but in the second instance the mortality rates of the
disadvantaged are now six times as high (450/75).
So the social class gap in health inequality in relative terms
has become larger.

Life Expectancy in the London Borough of Camden

11 years difference in life expectancy between social classes.
Hampstead (affluent) = 81 years for men
Somers Town (material disadvantage) = 70 years for men

Bloomsbury is a great place to live in that the life expectancy in

this region is significantly higher than the surrounding towns.
Suddenly there is a much lower life expectancy in Islington. This
sort of social discrepancy results in the differential health
outcomes that we see in society.
i.e Health outcomes due to Identifiable social differences
Conclusions
Individual biological development takes place within a social
context which structures life chances so that advantaged
and disadvantaged tend to cluster crossectionally and
accumulate longitudinally.
Advantages: eg nice area good school well off
background go to university well paid job etc. These

advantages cluster together and accumulate over the years.

The same happens with disadvantages.
Inequalities in health (and life chances in general) derive
from structured (social class) divisions existing within a
society.
(a) In outline, describe the differences in health outcomes that currently exist between
social classes in the U.K.
(b) Identify and briefly describe two social explanations that account for the
contemporary trend in health inequalities.