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2011/4 (No 143)

  • Pages : 224
  • ISBN : 9782707170071
  • DOI : 10.3917/her.143.0162
  • Publisher : La Découverte

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In the United Kingdom, the National Health Service (NHS) is part of the national heritage. For many British people, it represents a major social achievement, the very symbol of the welfare state. It was set up in 1948 by Labour Prime Minister Clement Attlee and his Health Minister Aneurin Bevan. Its three founding principles were to meet the needs of all, provide treatment free of charge in all of its institutions, and provide care based on patients’ clinical needs rather than their financial resources. In a country often regarded as especially liberal, the British remain deeply committed to the State’s central role as regulator and guarantor of the National Health Service. Thus the NHS symbolizes the role of the State within society and in citizens’ lives.


Because the NHS is such a symbolic institution, reforming it is an extremely sensitive political operation. In June 2011, David Cameron experienced this when he was forced to back down and postpone his reform plans after several months of protest by the Labour opposition involving patients and health professionals. A number of surveys showed that the British did not trust the Conservatives over the healthcare system, fearing extensive liberalization and a form of privatization of the NHS. Far from being forgotten, the policies of the Thatcher and Major governments, with their liberalizing tendencies, are often blamed for all the current woes of the system. Labour, on the other hand, by virtue of the political values it upholds, is traditionally seen as the guarantor of the public service it created. However, some of the policies pursued by the Blair and Brown governments were strongly opposed by the trade unions and their sympathizers within the Labour party.


As in many comparable countries, reforms to the public health service in the United Kingdom is essential to meeting current challenges such as the rising cost of care and treatment and an aging population, limiting public spending, and remedying the defects and failings of the system. In fact, the British public health system lags behind those of its European neighbors, with a cancer survival rate lower than that of the average for OECD countries, for example. In this context, protecting the NHS and its founding principles is of major concern to the British people. As a result, health is one of the country’s most sensitive domestic policy issues.


Since health is an indicator of social, regional, and ethnic inequalities within the United Kingdom, some reforms appear essential. Awareness of these inequalities is heightened through the regionalized and decentralized nature of NHS structures. In fact, there are four different and independent health services, one for each of the United Kingdom’s national components (England, Scotland, Wales, and Northern Ireland). Due to “geometrically asymmetrical” devolution (Bailoni and Papin 2009), the Scottish, Welsh, and Northern Ireland health systems fall under the responsibility of autonomous institutions. Meanwhile, the English NHS, which covers 85% of all British patients, is administered directly by the central government. From its inception, the system has operated in a decentralized manner through the intermediary of regional and local agencies responsible for hospitals in their sectors.


These disparities are at the root of the frustration and resentment experienced in regions that see themselves as disadvantaged and constitute a source of tension between regions: between local areas, between English regions, between England, Scotland and Wales, between local or regional and central authorities, and between communities. The issue of equity between regions and thus between citizens is often raised and has become a political and electoral concern, a focus of debate and even tension between citizens, and a territorial bone of contention. In brief, as for other European countries, health has become a real geopolitical issue for the United Kingdom (Giblin 1999; Lacoste 1999).

A National Health Service with Deep Regional and Social Inequalities

Does the Decentralized Organization of the Health Service Guarantee Attention to Specific Local Issues?


In England, the health service is subdivided into regional agencies, the ten Strategic Health Authorities (SHA), and local agencies, the 152 Primary Care Trusts (PCT), which all come under the authority of the Ministry of Health. [2]  With some exceptions, administrative divisions in healthcare...[2]


Map 1 shows the current PCT boundaries. Although these have altered since the NHS was created, they remain regionally based. [3]  Since 1948, a number of reforms have altered the boundaries...[3] The PCTs are the primary actors within the health system, being responsible for the organization and administration of services and public facilities. They control not only hospitals but also general medicine. In fact, most generalist doctors—or around 85%—are contracted to the NHS via the PCTs. This allows the PCTs to regulate the appointment of doctors within their area. In theory, the number of posts allocated to each PCT is a function of the needs of its area. Although there are major disparities between areas in the provision of doctors (see Map 1) and while certain shortages persist, the basis for these inequalities is not purely regional. In fact, largely rural areas, such as Cumbria, the Southwest, and Herefordshire as well as seriously deprived urban areas such as East London or Bradford have higher densities of doctors than the national average, whereas comparable areas in France such as Lozère, Meuse, Haute-Saône, or Seine-Saint-Denis are seen as medical deserts. However, we should emphasize that England has a much lower density of doctors than France, with the proportion of general practitioners being half that of France, or 70 per 100,000 compared to 139 in France. [4]  Sources: NHS and Conseil National de l’Ordre des Médecins,...[4]

Map 1 - Density of Doctors Corresponding Theoretically to the Needs of the Population of Each English Region

Together, the PCTs manage 80% of the NHS budget, a total of £89 billion (€101 billion) for the 2011–2012 financial year, an increase of 3% compared to 2010–2011. The allocation from the Department of Health varies considerably according to PCT, ranging from £1,367 per person in West Berkshire, an area to the west of London and one of the wealthiest in the country, to £2,350 for the London Borough of Islington, where some neighborhoods face major social problems. Public health spending per person thus varies by almost £1,000 according to area. However, the allocations made to the PCTs are calculated on the basis of a number of parameters, including the social and demographic features of the population and the performance of the local healthcare system in order to best respond to the needs of each area.


Map 2 shows that problematic urban areas, former industrial pockets, and some peripheral rural regions receive above-average funding. However, despite this highly regionalized system, deep disparities continue to exist within the country.

Map 2 - Public Expenditure on Health in England, by Region

Convergence of Regional, Social, and Ethnic Inequalities


In common with other social indicators, health data show important differences between regions within the United Kingdom. These inequalities are not unique to Great Britain but are found in all OECD countries, including in countries whose healthcare systems are often considered among the best in the world, such as Norway or the Netherlands. According to Eurostat regional data (2010), these inequalities are even greater in France. However, in the United Kingdom, they have been entrenched since the 1950s, though in a context where overall mortality rates continue to fall, a characteristically British feature. Yet health inequalities are much greater in the United Kingdom, where the issue of social and regional disparities lies at the heart of the political debate and has led to specific geopolitical interventions. In fact, a number of Members of Parliament and academics in Northern England, taking their inspiration from the Scottish and Welsh nationalists, are developing a regionalist critique and demanding greater funding for their region. They believe that the North has been the victim of central government incompetence and of its inability to resolve the economic and social problems found in the region. They see the region and its people as disregarded or even deliberately ignored by the economic and political elites in London or even in the South as a whole (Bailoni 2010). In this discourse, healthcare issues are added to other social problems.


The map of health indicators shows the classic image of a North-South divide that splits England in two. In fact, the results of the British census, which asks people about their state of health, clearly shows deep regional disparities. Figure 2 uses these data (Census, 2001), which are based on people’s perceptions of their health and clearly show that the population of the cities and former industrial areas of Northern England report being in worse health than those in the rural and peri-urban area around London. In general, the population’s state of health is worse in the North than in the South.


A number of studies that appeared regularly throughout the 1990s and 2000s addressed these inequalities, their persistence over relatively long periods, and their more recent exacerbation (e.g., Thomas, Dorling, and Davey Smith 2010; Hacking, Muller, and Buchan 2011). These conclusions may seem paradoxical since the regions with most problems appear to benefit from more generous medical staffing and higher funding. However, they show that these inequalities arise from multiple and extremely complex structural problems that are very difficult to address. Health indicators are also used in other, more general studies of regional socioeconomic disparities. Moreover, the media discuss these issues frequently and help to popularize the idea of a two-tier British healthcare system.


If we look more closely at the data, local disparities are even more marked. For example, male life expectancy may vary by over 13 years across local authorities [5]  Female life expectancy may vary by 11.5 years across...[5] (see Map 3). In fact, the situation may alter drastically within just a few miles. Hence, in the North-West, a man born in Blackpool, Lancashire, in 2007–2009 has a life expectancy of 73.7 years, almost six years lower than that of a man born some forty miles away in adjacent Cumbria (79.5 years). Similarly, while there is a clear North-South divide, there are also major local disparities across areas in terms of premature deaths [6]  This represents the number of deaths in the population...[6] as well as above-average mortality resulting from cardiovascular diseases and cancer linked to alcohol and tobacco consumption.

Map 3 - Local Disparities in Male Life Expectancy in the United Kingdom

These inequalities are even more noticeable at the neighborhood level. Thus male life expectancy varies by 17 years between neighborhoods within the London Borough of Westminster. It is also in the heart of London that we find both the highest and the lowest cancer survival rates in England. According to the Office for National Statistics (ONS), [7]  Data for 2006 for all types of cancer in the population...[7] only 56.3% of sufferers survive cancer in the London Borough of Newham, along with three further boroughs in East London, compared to 70.3% in the Borough of Hammersmith and Fulham, itself just ahead of two other areas in West London. In fact, East-Central London contains the most deprived populations in England, with these boroughs having some of the worst social indicators in the country. On the other hand, areas of the West End, close to centers of political power and the seat of the crown, are home to particularly wealthy residents.


To illustrate inequalities within London, the London Health Observatory, a public expert body, produced a map of the London underground Jubilee Line, showing that between the stations of Westminster and Canning Town, 9.3 km apart, male life expectancy fell by three years, that is, by one year for every two stops. The geographical proximity of these radically different situations reinforces the perception of disparities and fans resentment among sections of the population that feel abandoned and victims of an unequal and unfair system.


A number of factors combine to explain the dismal state of health in a given area: lifestyle, including diet, alcohol and tobacco consumption, exercise (or lack of it), and working conditions as well as poverty, housing conditions, education, and immediate environment. Thus the most socially disadvantaged areas are traditionally those with the worst health data, and vice versa. In fact, the determinants of health are primarily social, with the most disadvantaged social groups showing lower life expectancy and a worse state of health than among more privileged areas. As the Guardian newspaper headlined on July 2, 2010, “Poor in UK dying 10 years earlier than rich.” As elsewhere in Europe, data show clearly that senior managers have a healthier lifestyle in terms of tobacco and alcohol use and diet than do working class people. These behaviors, which are linked to other social insecurity factors, have a direct effect on survival rates for certain types of cancer (such as lung cancer), which are lower for the most disadvantaged social classes.

Figure 1 - Symbolic Representation of Variation in Life Expectancy in the Heart of London

When comparing the maps above, we may note that certain areas with poor health such as East London and large urban areas in Northern England have a relatively good provision of medical staff and higher health funding. Yet health disparities persist. These observations show that a given population’s poor state of health cannot be explained by a lack of medical provision, unlike in France, where certain areas can be described as healthcare deserts.


Linked to territorial and social factors is a number of ethnic disparities in health within the United Kingdom, which stand out clearly when health, demographic, and ethnic data are combined. Thus the infant mortality rate among British whites (4.5‰) is under half that of Pakistanis (9.6‰) or Afro-Caribbeans (9.8‰). [8]  Rate for children born in 2005. Source: ONS and NH...[8] Data on ethnicity from the 2001 census clearly show that overall, the health of ethnic minorities is worse than that of whites even if some trends are reversed in the case of gender: in white populations, men have worse health than women whereas among ethnic minorities, the reverse is true, very markedly so in the case of some minorities such as Indians, Pakistanis, and Black Africans. Inequalities between different ethnic categories, such as those between Pakistanis or Bangladeshis and Indians or Caribbeans may be explicable in terms of how long these communities have been settled in Britain (people from the Caribbean generally immigrated earlier than Pakistanis or Bangladeshis) or by the social origin of these populations. For example, many Indian immigrants were members of the urban middle class, whereas Pakistanis and Bangladeshis tended to come from lower class and rural backgrounds (Bailoni and Papin, 2009). However, such differences do not explain the gender gap in health found in some ethnic groups.

Figure 2 - Ethnic Inequalities in Health

Some of the areas already mentioned, particularly East London boroughs such as Newham, are also those where ethnic minorities, who are among the lower social class and lowest-income sections of the population, are over-represented. However, there is no exact geographical correspondence between health problems, social problems, and presence of ethnic minorities since, for example, white populations are over-represented in certain problematic areas such as the large conurbations of Scotland, Wales, and North-East of England.

Health in the United Kingdom: A Geopolitical Issue


Over and above being a political and social issue, health inequalities are a real geopolitical issue in the United Kingdom. Whether acknowledged or not, they are a source of tension between regions where this (and other) bones of contention exist. These are in part due to the highly territorially based organization of the health service in the United Kingdom.

Patients Facing a “Postcode Lottery”


While the factors accounting for these inequalities are many and complex, the healthcare system is often accused of exacerbating them or even of creating new regional inequalities for what are often seen as bureaucratic and arbitrary reasons. In fact, despite the principle of universality underlying the NHS and the regulatory role of the central government, not all British citizens appear to have access to the same services, the same treatments, or the same quality of care depending on their income, their community, or their place of residence. Merely by virtue of where they live, British people thus do not have the same likelihood of enjoying good health and do not benefit from the same life expectancy. Thus the British refer to a “postcode lottery” [9]  In the United Kingdom, each postal [zip] code corresponds...[9] to describe these sometimes inexplicable inequalities between adjacent neighborhoods. This expression, which emerged in the 1990s, shows that patients’ health is dependent on a form of chance. As in a lottery, there are winners and losers. [10]  The Guardian, November 9, 2000.[10]


The “postcode lottery” is thus seen as a consequence of the inadequate territorial organization of the NHS, which seems incapable of providing the same quality of care throughout the country. In fact, there is no strict regulation of how a PCT spends its budget and thus no truly national healthcare policy, which creates a number of inequalities between patients. Although the PCTs must observe the national priorities set by the government, they have a certain amount of autonomy as to how they do this depending on the particular characteristics of their region or similar considerations. Hence some costly treatments may be provided by one PCT and denied in the neighboring one. Depending on where they live, patients may or may not be able to access a particular treatment. Data published in 2007–2008 showed major disparities in the amount of money spent on cancer treatments between different PCTs. [11]  The Daily Telegraph, November 26, 2007 and September...[11] In Oxfordshire, for example, the NHS spends £5,182 per annum on each cancer patient, whereas in Nottingham, the figure is £17,082. Within London, the Hounslow PCT spends almost twice as much (£11,726) per patient as the neighboring Borough of Ealing (£6,650). This means that the lives of some patients are prolonged while others have the bad luck to live in the wrong area. According to Cancer Research UK (2011), in 2011, a lung cancer sufferer in Coventry would live for only 150 days after diagnosis as opposed to 224 days for a patient in Berkshire. [12]  However, we should note that social indicators such...[12] Similarly, the amount spent on mental health services varies considerably from one PCT to another. In 2011, two thirds of PCTs introduced restrictions on some non-urgent surgical operations such as cataract, tonsil and varicose vein removal, and hip and knee replacements. These operations are delayed if the patient is not in pain and is not at risk. The aim is to make savings. However, the list of restricted operations and their scope vary according to PCT, and the Department of Health does not issue clear guidelines on this or an official list of non-urgent operations. [13]  The Independent, July 28, 2011.[13]


As for non-urgent operations, in cases of serious illness, each PCT has its own strategy for restricting spending, which may be applied more or less strictly. Both the tabloid and the quality press regularly run headlines and articles denouncing this “postcode lottery,” both demonstrating and reinforcing one of the British public’s major concerns.

Health Inequalities: A Source of Tension between Areas


The issue of health inequalities is particularly sensitive in the United Kingdom as it reinforces other political issues and thus feeds into certain representations of identity and geopolitical grievances.


Health may thus contribute to complicating relations between the nations that make up the United Kingdom. In fact, the existence of specific health services for Scotland and Wales since 1948 has led to a degree of resentment among English people. Before the devolution of 1999, the NHS in Scotland and Wales was the responsibility of the Secretaries of State for Scotland and for Wales, respectively, that is, they depended directly of the central government. However, due to their own political traditions, the Scottish and Welsh health services did not adopt liberalization reforms, unlike the NHS in England. Since devolution, the Departments of Health in Edinburgh and Cardiff manage their respective health services with complete autonomy and pursue their own health policies. For example, the Scottish Executive has set up a completely free and universal system of care for old people that does not exist in England. In Wales, every patient below the age of 15 and over the age of 60 is entitled to free dental checkups, whereas in England, these have to be paid for. Similarly, some costly treatments for Alzheimer’s disease are available in Scotland but not in England. [14]  The Daily Mail, January 3, 2008.[14] The more socially oriented policies adopted by the authorities in Edinburgh and Cardiff can be explained by the values of their societies, which are more left leaning and oriented toward public services and the welfare state. They also aim for greater legitimacy by demonstrating to their fellow citizens that devolution can change their daily lives for the better.


Many believe that devolution had a favorable impact on Scottish and Welsh health services. In fact, reports by the Nuffield Trust, [15]  Source: Nuffield Trust, 2010, “Funding and performance...[15] an independent think tank recognized for its expertise in health issues, show that the Scottish, Welsh, and Northern Ireland healthcare systems are better funded than their English equivalent. For the 2008–2009 financial year, public spending on health and social care per person was 15% higher for a Scot than for an English person. [16]  Spending on health and social care was £2,212 per person...[16] The number of doctors and nurses is also higher in the peripheral nations. According to ONS, there are 5 hospital beds per person in Scotland as compared to 3.1 in England. [17]  There are 4.4 hospital beds for every 1,000 person...[17] However, indicators also show that health services in England are more efficient, with shorter waiting lists, for example.


The advantages enjoyed by the Scots and the Welsh are frequently emphasized in the right-wing press, particularly the Daily Telegraph and the English tabloid press, which are opposed to devolution and to more socially oriented policies, in order to denounce the privileges granted to the Scots for decades and maintained by New Labour when in power. For example, the Daily Mail headlined in 2008 the view that “Devolution has created four different health services, and England is the poor relation,” [18]  The Daily Mail, January 3, 2008.[18] echoing the conclusions reached by Andrew Lansley, then a Conservative member of Parliament and later Health Minister in the Cameron government. These so-called privileges have also been denounced by many patients’ associations in England. Many Members of Parliament in the North also regret that their constituencies, whose social characteristics are similar to those in Scotland, do not benefit from the same privileges. For the English, these advantages are all the more scandalous in that NHS Scotland and NHS Wales are entirely dependent on central government funding and hence on English workers and taxpayers.


However, if there are major inequalities between England and Scotland, these also exist between regions of England. As shown in Table 1, if we take an average index of 100 for health spending per inhabitant in the United Kingdom, England has an index of 99 while in Scotland it is 108. However, the North-East of England has an index of 109 and London of 112, compared to only 89 and 92 for the East and Southeast, respectively. Although these differences make sense when the poor state of health and hence the specific needs of certain areas are taken into account, the image of a privileged Scotland as compared to England is deeply rooted. The question of health reveals the frustration and resentment of some sections of the population in these areas, who feed into discourses and geopolitical attitudes based on opposition to devolution and on English and regional nationalism.

Table 1 - The Unequal Division of Public Spending, by Nation and Region

Note: The table shows spending per person expressed as an indicator (base 100 = whole of the United Kingdom) by sector for the 2009–2010 financial year.

Source: HM Treasury, 2010, Public Expenditure Statistical Analyses 2010

Beyond the issue of public spending, health is also symbolic of constitutional disparities between the different British nations. In fact, while England does not benefit from devolution, the British government and Parliament are directly responsible for the management of the health service. As a result, Scottish members of the House of Commons can vote and debate on health policy in England, but their English counterparts have no real influence on measures adopted in Scotland. This is the constitutional paradox produced by “asymmetrical devolution.” Since 1999 this problem has resurfaced regularly to sour relations between London and Edinburgh as well as debates in the Westminster parliament. In fact, to ensure that laws on the English NHS were passed, the Blair government needed the votes of Scottish Labour MPs [19]  This was the case, for example, with the Health and...[19] (Lodge, Russell, and Gay 2004). In 2003, the Conservative opposition leader also called into question the legitimacy of John Reid, a Scottish MP, appointed British Health Minister and thus responsible for health in England but not in Scotland. Iain Duncan Smith, then leader of the opposition, spoke of a “deformation of democracy” and the Daily Express of an “Outrage to England.” [20]  The Daily Telegraph ; Daily Express, June 14, 2003[20]


Within England itself, health inequalities also give rise to resentment. People in the most disadvantaged areas such as the post-industrial regions of the North, London neighborhoods with multiple problems, and peripheral rural areas believe that they have been neglected compared to more favored areas. This impression is all the stronger given that health issues are superimposed on other problems such as structural unemployment, financial fragility, crime, and educational failure and thus reinforce frustration and discontent. Fully aware of the scope and consequences of these problems, the Labour Party made fighting inequality one of the main planks of its health policy when it was in power.

Modernizing the System and Addressing Inequalities: Election Promises versus Political Reality. Modernizing the NHS: The New Labour Approach


In 1997, New Labour inherited a health service that had already undergone substantial reforms at the hands of the Thatcher and Major governments, which were accused of deepening inequalities and leaving the health sector in a perilous situation and lagging behind other European countries. The main Conservative innovation was to split healthcare providers (essentially hospitals) from purchasers (local NHS trusts and some independent general practitioners).


The Labour party was elected on an ambitious manifesto for public services. However, the Blair government did not at first carry out any revolutionary reform of the NHS. Rather, it continued the policies of its Conservative predecessors and was content to bring in only a few regulations and adaptations (Kober-Smith 2010). It reversed certain aspects seen as too neoliberal and took advantage of the experience acquired to put right certain defects. It adapted the system in place to its political vision but without any radical transformation. Thus, New Labour pursued its Third Way strategy in the field of healthcare as in many other areas of public policy (Bailoni 2009). For example, in order to limit public spending, the Blair government retained and used the Private Finance Initiative (PFI) [21]  PFIs are agreements between the private sector, which...[21] system after 1997 even though the Labour Party had condemned this when it was introduced by the Conservatives in 1992. Among the adaptation measures taken in the health service, the government introduced regulatory and inspection commissions, healthcare quality indicators, and performance criteria in an attempt to regulate and harmonize the health service at the national level. [22]  Thus the Labour Government set up the National Institute...[22]


However, more ambitious measures were ruled out by New Labour’s election promise to set strict limits on public spending for two years. As a result, the situation in hospitals did not improve, with 1.3 million British people having to wait for operations in April 1998. In the face of public concern and voter dissatisfaction, in 2002, the Blair government initiated an unprecedented policy of public investment and job creation. The situation of the NHS improved and it managed to recover some of the ground it had lost. In parallel, the Department of Health imposed far stricter controls on hospital management and the quality of care. This strengthened the role of the government, marking a crucial departure from the practices of the 1980s and 1990s.


After 2002, however, New Labour altered its policies and introduced two major changes. On the one hand, it wished to encourage competition between healthcare providers by allowing patients to choose which hospital should treat them. On the other, the Department of Health increased private investment in the health sector. In addition to the PFIs, contracts were signed with private hospitals to carry out certain operations, and foundation hospitals—half public, half private, with a high degree of autonomy—were set up. Sometimes accused of being influenced by certain private sector lobbyists, New Labour thus favored the idea of a mixed system regulated by both the State and the market (Kober-Smith 2010).


However, the use of private capital to finance health infrastructure proved to be the cause of discord between the New Labour government and the trade unions, which despite their historical support for the Labour movement, did not hesitate to launch overt criticisms of the government and even lent their support to the independent candidate Richard Taylor, who won the previously Labour seat of Wyre Forest (West Midlands) in the 2001 general election with a sole program of safeguarding the emergency department at Kidderminster hospital. This example highlights the conflict between New Labour in power, proponents of the Third Way, and the Labour unions, which are more attached to traditional Labour values and the welfare state. It also underlines the expectations of the electorate with regard to health issues and the disappointment felt with the actions of the Blair government.


In all, the Blair and Brown governments created 340,000 jobs in the NHS in England between 1997 and 2010, representing a 40% increase in the workforce. [23]  In fact, the salaried workforce of the NHS increased...[23] New Labour showed a firm determination to make lasting investments in the sector, and even during the financial and economic crisis of 2008, the Brown government maintained its public spending program at the risk of aggravating the budgetary imbalance. Between the 1997–1998 and 2009–2010 financial years, the United Kingdom’s health budget doubled, rising from £59 billion to £119.8 billion and from 5.3 to 8.5% of GDP. [24]  Amounts are expressed in pounds at constant prices...[24] Thus we now need to examine the impact of this massive investment and of New Labour policies on reducing regional inequalities overall, an issue that lies at the heart of debates over public health in the United Kingdom.

Challenging Inequalities: Social Action and Territorial Strategies


The struggle against health inequalities had been a Labour preoccupation since the 1970s. The Black Report, commissioned by the Labour Government of James Callaghan in 1977, produced a highly detailed analysis of the situation and made recommendations for reducing disparities. However, on its publication in 1982, it was ignored by the Thatcher government. When it was returned to power, the Labour government commissioned a new expert study, the Acheson report, which was published in 1998. These two reports underlined the impact of social determinants of health, demonstrated the importance of reducing social inequalities in order to reduce disparities in health, and recommended parallel action on education, local public services, and housing (Health Committee 2009).


The Acheson report’s conclusions influenced New Labour policies. In fact, once in power, New Labour made reducing these disparities a frequently emphasized priority of its public service policies. The white paper The New NHS: Modern, Dependable, published in 1997, defended the original principles of the health service in terms of equality of access to healthcare in the whole country, as did a second white paper, Saving Lives: Our Healthier Nation, published in 1999. In 2000, the NHS Plan announced a series of reforms and an ambitious goal of bringing about a 10% reduction in inequalities in life expectancy and infant mortality within ten years. Finally, the document published by the Department of Health in 2003, Tackling Health Inequalities: A Programme for Action, set out a complete public health policy with four priorities: support for families and children, prevention, access to quality care, and action on social determinants.


As elsewhere in Europe, the NHS launched prevention campaigns targeting smoking, alcohol abuse, and obesity and made the diagnosis of cardiovascular disease and cancer a priority. However, the Blair and Brown governments also specifically sought to encourage partnerships between health services (via the PCTs), local authorities, and neighborhood associations in order to develop strategies adapted to each local area.


As soon as it came to power, New Labour also put in place locally based actions in an attempt to reduce health inequalities. Hence, in 1997, the government defined 26 Health Action Zones (HAZ) in 26 particularly disadvantaged areas, where specific health measures were to be put in place. This plan was announced the day after the publication of a report that showed disparities in the cure rate for cancer. These HAZs were urban areas of London, large post-industrial cities in the North, and outlying rural areas such as Cornwall and Cumbria. While they were initially hailed as good examples of New Labour’s Third Way, they were soon judged to be ineffective and were dropped in 2003.


However, adopting a similar approach, in 2006, the Blair government designated 70 Spearhead Areas in the most disadvantaged parts of the country. Targeted actions involving PCTs and local authorities were carried out, financed by specific funding. To support these measures, a National Support Team of health specialists was set up to help and advise these areas in finding solutions, a program that was later continued by the Cameron government. While local initiatives were encouraged, these remained subject to parameters set by the Department of Health by means of directives and strict financial controls. The strategy of promoting local partnerships adapted to local circumstances thus went hand in hand with a move toward the centralization of regulation and control.


In parallel to these specific measures, the Labour government included measures aiming to improve the health of the population as part of more general social policies in the form of aid to disadvantaged areas or through urban renewal programs. For example, health formed a central plank of the Sure Start program set up in 1998 to improve the lives of some of the poorest children in the country. Social and health measures were also at the heart of New Labour’s flagship urban renewal programs, the New Deal for Communities and the Neighborhood Renewal Strategy (Bailoni 2009). Health policy thus formed part of New Labour’s wider approach to territorial planning.


However, despite all these measures and announcements, New Labour appears to have failed to significantly reduce the country’s health inequalities, with a number of press articles and reports showing that these disparities were persisting or even worsening. Although their content was sometimes politically partisan and difficult to verify, the conclusions of the most objective and well-respected analyses all seemed to point in the same direction. Thus, a House of Commons health committee report published in 2009 showed that the state of health of all categories of the population had improved for all social groups over the previous ten years. Yet over the same period, inequalities had worsened. In fact, the health of the richest had improved significantly more than that of the poorest. The conclusions of a report published in 2010 by Parliament’s National Audit Office were very similar. [25]  The Guardian, July 2, 2010.[25] As geographers Thomas, Dorling, and Davey Smith (2010) also showed, geographical inequalities were worsening. In particular, they revealed that disparities in the premature death indicator were in fact greater than in 1921.


The conclusions of the Marmot report, commissioned by the Brown government and published in February 2010, once more described deep disparities across the country, emphasizing the fact that “social injustice is killing on a grand scale.” (p.16) It observed that the measures taken so far had been ineffective and recommended action on the social determinants of health, especially for young children. It called for more work to be carried out in partnership at local level, involving not only political authorities but also citizens and local communities. In short, its conclusions were very similar to those of the Acheson report of 1998 and even the Black report of 1982.


Criticism of New Labour’s actions frequently focused on the inadequacy of the measures adopted in relation to the complexity of the nature and causes of the disparities (Health Committee 2009; Marmot 2010). Many claimed that the funding allocated was too little in relation to the scope of the problem. Critics also emphasized the lack of any long-term perspective. Measures were often introduced in response to an immediate problem rather than as part of a long-term program. Finally, the efforts and actions of both the government and the NHS appear to have been dispersed among programs that lacked cohesion, a common goal, and complementarity (Judge and Bauld 2006).



Although it chose not to reduce spending on health in contrast to other areas of public spending, the Cameron government intends to carry out major NHS reforms in order to make savings and improve efficiency. Up to now, it has failed to impose significant changes what would be acceptable to the public, which is ever vigilant in defense of the NHS. In fact, the Prime Minister has little room for maneuver, trapped between his own party, which demands more decisive policies, and his Liberal-Democrat coalition partners, who have set their own conditions.


While the struggle against inequalities has been at the heart of debates over the NHS since the 1990s in the United Kingdom, it remains a major political issue that is particularly sensitive in the current social context. The resentment felt by the population of some areas and the popularity of expressions such as the “postcode lottery” are also a consequence of the failure of successive governments to reduce geographical disparities in health, and, more broadly, social inequalities.


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[1] PhD in geopolitics, Lecturer at the Centre de Recherches et d’Analyses sur les Paysages (CERPA), Université de Lorraine.

[2] With some exceptions, administrative divisions in healthcare follow regional and local authority boundaries.

[3] Since 1948, a number of reforms have altered the boundaries and names of these regional and local units, with the main reorganizations taking place in 1974, 1982, 1994, 1996, and 2002. The last one took place in 2006, when the number of SHAs was cut from 28 to 10 and that of PCTs from 303 to 152.

[4] Sources: NHS and Conseil National de l’Ordre des Médecins, 2011.

[5] Female life expectancy may vary by 11.5 years across local authorities. While the London Borough of Kensington and Chelsea has the longest life expectancy (89 years for women, 84.4 years for men), Glasgow has the lowest (77.5 years for women and 71.1 years for men). Meanwhile, Manchester has the lowest female life expectancy in England (79.1 years) and Blackpool the lowest male life expectancy (73.7 years).

[6] This represents the number of deaths in the population aged 65 or younger.

[7] Data for 2006 for all types of cancer in the population aged between 15 and 99.

[8] Rate for children born in 2005. Source: ONS and NHS.

[9] In the United Kingdom, each postal [zip] code corresponds to a very small area, sometimes a single street or even part of one. Although there is no rationale for this other than operational reasons on the part of the Royal Mail, some postal districts have acquired a certain symbolic, even identity-forming dimension for the British. For example, a BBC news item reported the desire of residents of the up-market towns of Windsor and Maidenhead to change their “SL” postcode to “WM” as the “SL” prefix stands for the somewhat lower-status town of Slough, which is famous for its social problems and high crime rate. This is not only a question of prestige but also of house prices and insurance premiums, which are sometimes calculated on a postcode basis (BBC News, “The power of the postcode,” April 5, 2005. Accessed from: http://news.bbc.co.uk/2/hi/uk_news/england/london/4409163.stm).

[10] The Guardian, November 9, 2000.

[11] The Daily Telegraph, November 26, 2007 and September 8, 2008.

[12] However, we should note that social indicators such as income, unemployment rates, and number of skilled workers are far more favorable for the population of Berkshire than for that of Coventry.

[13] The Independent, July 28, 2011.

[14] The Daily Mail, January 3, 2008.

[15] Source: Nuffield Trust, 2010, “Funding and performance of healthcare systems in the four countries of the UK.”

[16] Spending on health and social care was £2,212 per person in England, £2,544 in Scotland, £2,494 in Wales, and £2,330 in Northern Ireland. Source: ONS, 2010, United Kingdom Health Statistics 2010. These data are based on information from the British Treasury.

[17] There are 4.4 hospital beds for every 1,000 person in Wales and 4.3 in Northern Ireland. Source: ONS, 2010, United Kingdom Health Statistics, 2010.

[18] The Daily Mail, January 3, 2008.

[19] This was the case, for example, with the Health and Social Care (Community Health and Standards) Bill passed in the House of Commons with a slim majority of 35 votes (286 for, 251 against) thanks to support from Scottish and Welsh MPs. In fact, only English MPs voted with a very narrow majority against (218 against, 217 for).

[20] The Daily Telegraph ; Daily Express, June 14, 2003.

[21] PFIs are agreements between the private sector, which provides capital for building or renovating infrastructures, and the public sector, which leases them for a period of about thirty years. The benefit for the State lies in not having to enter into debt to finance these projects and being able to stagger its spending. Detractors of PFIs point out that the final bill for the taxpayer is far larger than it would be with direct public investment.

[22] Thus the Labour Government set up the National Institute for Clinical Excellence (NICE) in 1999 and the Health Development Agency in 2000. The two agencies were merged in 2005.

[23] In fact, the salaried workforce of the NHS increased from 846,298 full-time equivalents in 1997 to 1,186,571 in 2010. During the 2000s, two-thirds of newly appointed doctors and 40% of nurses came from abroad, essentially from Commonwealth or East European countries. Source: NHS Information Centre, Workforce Census, 2011.

[24] Amounts are expressed in pounds at constant prices on the basis of the 2009–2010 financial year. Source: House of Commons Library, 2011, NHS funding and expenditure.

[25] The Guardian, July 2, 2010.



Healthcare data reveal social, regional, and ethnic inequalities in the United Kingdom. Although the struggle against these disparities has been at the heart of the debate on public services since the 1990s, it remains a major political issue of particular sensitivity in the current social context. The grievances and frustrations experienced in some areas and the popularization of metaphors such as the “postcode lottery” are the consequence of the failure of successive governments to reduce geographical as well as wider social inequalities. This has become a political and electoral issue and a focus for debate—even tension—among citizens and between regions. Thus as in other European countries, healthcare has become a real geopolitical issue in the UK.


  1. A National Health Service with Deep Regional and Social Inequalities
    1. Does the Decentralized Organization of the Health Service Guarantee Attention to Specific Local Issues?
    2. Convergence of Regional, Social, and Ethnic Inequalities
  2. Health in the United Kingdom: A Geopolitical Issue
    1. Patients Facing a “Postcode Lottery”
    2. Health Inequalities: A Source of Tension between Areas
  3. Modernizing the System and Addressing Inequalities: Election Promises versus Political Reality. Modernizing the NHS: The New Labour Approach
    1. Challenging Inequalities: Social Action and Territorial Strategies
  4. Conclusion

Translated from the French by JPD Systems

To cite this article

Mark Bailoni, “ Les inégalités territoriales et les enjeux géopolitiques de la santé au Royaume-Uni ”, Hérodote 4/2011 (n° 143) , p. 162-183
URL : www.cairn.info/revue-herodote-2011-4-page-162.htm.
DOI : 10.3917/her.143.0162.

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