Introduction: the 1998 White Paper

The 1998 White Paper Better Health – Better Wales (Welsh Office, 1998) addressed the issues that most directly affect the health of people in the Sustainable Health Action Research Programme (SHARP) areas. The White Paper recognised the social causes of ill health and also noted that while health in Wales was slowly improving from a low base, health inequalities persisted (§6.16). In proposing policies to address poor health in Wales, the White Paper specifically aimed to reduce health inequalities (§6.16, 7.10), although, as in England (Graham, 2004), resulting policy documents employed the term ‘health inequalities’ in a number of different ways.

The White Paper laid great stress on multidisciplinary collaborative and intersectoral approaches within the health services. It asserted that health services could not be engaged in health promotion by themselves and that social and physical environments also needed to be improved; that people need to feel safe from crime to be free from the anxieties that can undermine health and wellbeing (§3.11); and that good housing is essential for health (§5.3). Furthermore, people were more likely to be healthy in work that out of work (§3.5). Agencies working in the fields of health, education, criminal justice and the environment were not just to collaborate with one another, but were to form partnerships with local communities. Thus, the White Paper went beyond advocating an integrated health service: ‘Long-term action is needed to tackle the root causes of health and economic inequality. This may mean a new approach to maintaining health and to using health and social care services as a community resource’ (§3.4).

The idea of publicly provided services being a resource was innovative if not revolutionary. Since its inception, the NHS has been providerled, but according to the White Paper, health authorities were to have ‘duties of partnership’ (§6.15) and health improvement programmes were to include locally determined priorities (§7.13), although how local is not stated. Chapter Six of the White Paper sets out a vision of partnership between a range of agencies and local communities, acting together to promote the health of the Welsh population. Forged in the euphoria of the founding of the Welsh Assembly and informed by the large body of research accumulated in medical studies and sociological research, the White Paper adopted a progressive approach to health and health service delivery.