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In July 1997, shortly after the election of the new Labour government in the UK, the Secretary of State for Health asked Sir Donald Acheson, the recently retired Chief Medical Officer, to head an inquiry into inequalities in health in England and identify priority areas for policies to reduce inequalities.
Sir Donald Acheson's report adopts a broad socioeconomic model of health and inequalities.1 This model places individuals at the centre of many layers of conditions that determine their health, for example, their lifestyle, social and community networks, living conditions, and general socioeconomic conditions. As well as examining physical and mental health, the inquiry team sought evidence of the effects of unemployment, low income, housing, transport, and education.
There are two overarching recommendations. First, that as part of health impact assessments, all policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities. They should be formulated in such a way that by favouring the less well off they will, wherever possible, reduce inequalities. Mechanisms to monitor progress should be developed and better data collected to evaluate the effectiveness of these policies. Second, a high priority should be given to policies aimed at improving health and reducing inequalities in women of childbearing age, expectant mothers, and young children.
The report goes on to make a wide range of recommendations. In relation to reducing inequalities in childhood injury it states that more should be done to improve housing, particularly temporary accommodation, to encourage walking and cycling and reduce traffic speed, and to provide social and emotional support for parents and children.
In addition to these specific recommendations, the inquiry team also recommended that the needs of minority ethnic groups be specifically considered in the development and implementation of policies aimed at reducing inequalities. They called for a more appropriate allocation of resources to take account of the needs of communities at greatest risk.
There is also a plea for policies to develop the capacity for tackling health inequalities. For example, it recommends that directors of public health produce an equity profile for the population they serve, and undertake a triennial audit of progress towards achieving objectives to reduce inequalities in health. It suggests that there should be a duty of partnership between the health service and regional government to ensure that effective local partnerships are established between health, local authorities, and other agencies and that joint programmes to address health inequalities are in place and monitored.
Sadly, the section that details current inequalities deals mainly with mortality and morbidity rates of adults. Little is said about inequality in childhood injury. Yet accidental injuries have the steepest social gradient of any form of death in children and young people. The recommendations are in the main rather vague and many simply recommend further development of existing strategies. However, these disappointments should not conceal the powerful impact this report is likely to have. If all housing, environmental, transport, and educational policies in England as part of their health impact assessment have to take into account the health impact on children living in poorer families, we could see substantial changes to those policies. Moreover, the forthcoming government white paper on public health is likely to set new targets for reducing childhood injury and inequalities in health. This will add impetus to the implementation of the recommendations.
This raises a number of challenges for the Child Accident Prevention Trust and other organisations committed to reducing childhood injury. Although we may criticise the report for being thin on detail about inequalities in childhood injury, we have not successfully made the case for it to be the cornerstone of any strategy to reduce inequalities in health. We have not yet shown, although we believe it to be so, that childhood injury leads to high levels of permanent disabilities, lowered educational attainment, emotional distress, family break-up, and long term economic hardship. We do not know whether injury sustained in childhood leads to physical or emotional health problems in later life. It is also not clear which interventions are effective in reducing inequalities. Interestingly, a recent trend analysis of socioeconomic differentials in deaths from injury in childhood in Scotland suggests that growth in inequalities may not be an UK-wide phenomenon.2 The authors of the analysis are not sure of the reasons for this difference but put forward three possible explanations. One is that injury prevention measures have an equal effect in Scotland; another that the decline occurred independently of prevention efforts. Or it may be that different measures of inequality (area based in Scotland as opposed to individually based in England) yield different results.
Whatever the explanation, tackling inequalities in childhood injury presents a major challenge for government, academic researchers, and organisations committed to implementing effective prevention strategies.
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