Introduction

Like many other health systems, the NHS has been regarded as more like a sickness than a health service, failing to place health before healthcare, and to focus ‘upstream’ on the ‘social determinants of health’ (SDH) (for example, Wanless 2002; Marmot and Wilkinson, 2005; Hunter 2016a). This has implications for both aggregate health and health inequalities. First, while life expectancy in the UK in the twentieth century increased 38 years for men and women, equivalent to an increase of 4½ months per year (ONS, 2015), much of this improvement in life expectancy and health status more generally, is associated with the SDH (Marmot, 2010). It has been estimated that only 10–25 per cent of the health of a developed population is attributable to the healthcare system (McGinnis, Williams-Russo and Knickman, 2002: 83; Harrison and McDonald, 2008: 165). However, only ‘around 5% of the total UK government healthcare expenditure’ is devoted to preventive healthcare, with about half of NHS staff not regarding prevention as a core part of the work of their organisation (Faculty of Public Health, 2019; see also Exworthy and Morcillo, 2019).

Second, the temporal pattern for health inequalities is more complex. There has long been a recognition of health inequalities in terms of geographical and social class differences in life expectancy since at least the Chadwick Report 1842 (for example, Bambra, 2016). However, while overall health, in terms of life expectancy, broadly increased for much of the twentieth and early twenty first century before stalling or reversing in recent years (Marmot et al 2020a), health inequalities have increased at some times and reduced at others. For example, according to Robinson et al (2019), absolute inequalities in the infant mortality rate (IMR) increased between the most deprived local authorities and the rest of England between 1983–1998, decreased during the period of the English health inequalities strategy (1999–2010), but increased again in the period 2011–2017.

This chapter will thus examine the ways in which the NHS has addressed the issue of health and health inequalities. First, it focuses on four chronological periods of policies on health and health inequalities in the 75 years of the NHS. Then, it explores health and health inequalities through the four analytical lenses introduced in Chapter 1, before moving to evaluate policies concerned with health and health inequalities.