Hold your nerve - equality is not an expensive indulgence

Health secretary Alan Johnson has some justification for arguing Labour has had success in increasing the life expectancy of the most deprived. The trouble is, while the lifespan of the poorest has crept up, that of the wealthiest has rocketed.

The articles in this edition reveal how the NHS is left to deal with the effects of inequalities often beyond its direct control in education, housing, work and income.

Although it cannot tackle these wider issues directly, it can and must drive out inequality in the health service itself.

Government plans to increase GP coverage will help tackle one cause of inequality - simply getting access to medical care.

Once these new surgeries are in place, they face a formidable challenge in improving the use of preventive services among deprived communities - everything from vaccinations to cancer screening.

Part of the problem

But the health service cannot hope to ameliorate inequalities caused by wider society if its own actions exacerbate the problem. As HSJ reveals this week, primary care trusts are routinely underfunding deprived areas to overfund affluent ones. The inverse care law is alive and kicking.

In terms of practice based commissioning, this delivers precisely the opposite of what is needed. GPs get to keep the surpluses they make from their PBC budgets for reinvesting in innovative - and often preventive - care services. But if poor areas are getting less than they should, they will be the ones least likely to be able to invest surpluses in new services. The underfunding problem becomes a vicious circle.

PCTs need to get a grip on this, which means having the courage to embark on difficult conversations with local doctors.

As public finances tighten, action to tackle health inequalities will be under threat. For example, unemployment will worsen health disparities; mental health services in particular will be under pressure as the collapsing economy hits those at the bottom hardest.

This is when the advocacy role of the NHS will be paramount. As Sir Michael Marmot argues, no-one knows or cares more about health inequalities than the people who work in healthcare. The modern NHS is plugged into a range of local networks and partnerships; it needs to exploit these to encourage other parts of the community fabric, such as schools and councils, to play their role.

The tussle over funding between preventive and acute services will intensify in the next few years.

Worthy services

The problem for preventive services is that it is infinitely more difficult to demonstrate their worth; with hospital care the costs and outcomes can be finely calibrated, but judging the success of, for instance, a particular campaign to tackle teenage pregnancy is far harder.

There is a risk that strategies such as using social marketing to uncover unmet health needs will begin to look like an expensive indulgence when hospitals are grappling with the realities of zero growth.

But PCTs need to hold their nerve. Losing focus on tackling health inequalities will only store up more problems for the future.

As the financial glory days of the last decade give way to a more austere era, tighter finances mean preventive services are an even higher priority. Health equality is not just a luxury for the good times.

Can the NHS continue to reduce inequalities in a recession? Email hsj.feedback@emap.com