With reference to the literature, discuss the influence of social class on health and healthcare.
The fact that inequalities in health and healthcare provision exist in the United Kingdom today is beyond doubt. These inequalities can be attributed to several factors such as poverty, age, gender, ethnicity and social class. This essay will concentrate specifically on the influences of social class. Social class is a form of stratification within society, based on economic differences in the population. While many social and political commentators may try to portray Britain as a classless society, it clearly is not, although class distinction is less important now than it used to be only a few decades ago. Karl Marx in 1864 proposed two social classes, the bourgeoisie or upper class and the proletariat or working class. Against a background of poverty and oppression in Europe at the time, this was an important distinction, with associated ambitions for change. Max Weber in 1925 proposed divisions based on additional criteria, such as status, skills, prestige, income, wealth, education and qualifications. (Oxford Open Learning, 1995). The Black Report defined social class as: “Segments of the population sharing broadly similar types and levels of resources, with broadly similar styles of living and some shared perception of their collective condition.” (Black, 1980a p39).
The measurement of social class in Britain is important in the attempt to study and address inequalities in many areas of life, notably education and health. The occupation-based Registrar General’s Classification of 1911 identified six social classes: 1 – Professional (eg. doctor, lawyer, 5% of the population), 2 – Intermediate (manager, teacher, 18%), 3N – Skilled Non-Manual (secretary, office worker, 12%), 3M – Skilled Manual (bus-driver, technician, 38%), 4 – Partly Skilled (postman, farm worker, 18%), 5 – Unskilled (cleaner, labourer, 9%).
There are many problems with this categorisation of people into social classes based on occupations. Wives are given the same social class as their husbands, when in fact their own occupation may suggest a higher or lower class. A couple from a lower social class who both work, may enjoy a better lifestyle than a single person from a higher social class. Occupations are sometimes reclassified, as they tend to change in terms of status and the number of people engaged in them. There is considerable variation of income between occupations in the same class and a person is assumed to keep the same social class, regardless of a change in disposable income on retirement. More recently (2001) the Office of National Statistics defined ten social classes, making a finer distinction between professions, many of which have changed in categorisation and percentage of the population engaged in them. This is particularly true of the reduced numbers of workers in social class 5.
Health means different things to different people, depending on their usual or desired levels of physical and mental activity. Measurements of the health of a population can take many forms but mortality and morbidity rates are frequently used. Disability, infant mortality and rates of acute and chronic sickness and absence from work can also be valuable indicators. (Black, 1980b p37). The meaning of inequality is that there are differences in condition or experience among populations which have been brought about by social or industrial organisation and which tend to be regarded as undesirable. (Black, 1980c p42).
Those in the lower social classes, whose experience or condition is undesirable include unskilled manual workers, single parents, pensioners, the unemployed or underemployed, people with disabilities, people who do not own a car, people receiving income support, people whose income is set by means-tested benefit and those who live in social housing.
Many independent consultative bodies have provided evidence for health inequalities between social classes. The Black Report of 1980, Margaret Whitehead’s The Health Divide of 1988, updated in 1992, The Acheson report of 1998 – all have concluded that a health divide exists in the United Kingdom. Moreover, they have shown that the divide is growing and indeed its growth is accelerating. “The latest evidence shows that health inequalities are continuing to widen, in line with the long-term trend, despite more intensive and extensive efforts to address these issues in the last few years than ever before.” (DoH, 2005).
The Black Report on Inequalities in Health in 1980 highlighted several important points stressing the link between health and social class. A child born at the bottom of the social scale is twice as likely to die at birth or in the first few months, as a professional class child. For every boy from class 1 who dies before his first birthday, there will be two from class 3B and four from class 5. Of thirty-eight causes of death for children aged between 1 and 14, twenty-two showed manual working class children more at risk than the professional classes, with only asthma showing the reverse. For children under seven, the percentages not visiting the dentist and not being immunised against smallpox, polio, etc. rises the further down the scale. For example, the figures for smallpox immunisation were that only 6% of class 1 had not been immunised, against 14% of class 2, 16% of class 3A, 25% of class 3B, 29% of class 4 and 33% of class 5.
Among the adult population, the death rate from coronary heart disease (CHD) is three times higher for unskilled manual men (social class 5) of working age than for professional men (social class 1). In addition, the death rate from CHD for professional men has halved in the last twenty years, while remaining almost the same for unskilled manual men. This provides another example of the health gap continuing to widen. (Van den Bergh, 1998).
Smoking has developed a marked social-class gradient in the last fifty years, due to a decline in prevalence among non-manual workers. A similar gradient appeared among English teenagers in the 1990s. Health professionals have a major role to play in helping smokers to give up the habit, as even brief advice from a GP can lead up to 5% of smokers to quit. (Reid, 1996).
A survey of neurotic disorders showed that they were more common in women of social classes 4 and 5 than social classes 1 and 2. A similar but less marked pattern was found for men. (OPCS, 1995) As early as 1963, established a correlation between social class and occurrence of schizophrenia in young men and moreover, a drift downward in social class compared to their family’s original social class: the drift being attributed solely to their schizophrenia. (Goldberg and Morrison, 1963).
There are four main types of sociological explanations for differences in health between the social classes. (Taylor et al. 2000). Social constructivist explanations claim that much evidence is invalid due to unreliable methods and inadequate constructions of key concepts. A statistical bias results from applying some labels of disease more readily to people of different social classes. A social selection explanation assumes that the evidence is valid but that causes are in fact reversed. Individuals with poor health are unable to rise out of a lower social class, or indeed may fall in social class because they cannot stay in employment. Materialist-structuralist explanations focus on the differing material circumstances that accompany a person’s social class. Those who are better off or better educated will be able to direct more of their resources to the health of themselves and their family. Cultural-behavioural explanations attribute differences in health and healthcare to the supposed differing norms, values, knowledge and behaviours of the different social classes.
All these explanations are significant but the weight of evidence seems to suggest that it is the cumulative effect of people’s material and social circumstances that are the most important determinants of health inequalities. (Vagero and Illesley 1995). Clearly, class status has some association with economic status. Good health can improve ones socio-economic position, as the individual is better able to participate competitively in the job market. The likelihood of increasing ones life chances is therefore greater if one enjoys continued good health. Social mobility can thereafter be anticipated to rise, while poor health can become an obstacle to progressive social mobility. (Healy 1998).
In “An Introduction to Medical Sociology”, Tuckett (1978) produces more details on the class dimension to inequality. He suggests that the unskilled manual worker is 43% more likely to die between the ages of 15 and 64 than the average person, and 93% more likely to die from an industrial accident. He points out that the middle class are more likely to benefit from ante-natal and post-natal care, the services of a chiropodist in old age, and they are more likely to have their own teeth.
It has become the mission of successive governments to promote healthy living, to improve the health of disadvantaged sections of society and to narrow the health gap. However, whilst acknowledging that a health gap exists, some politicians have searched for explanations that distance the government of the day from any responsibility. Following the Black Report, Edwina Currie, Conservative health minister under John Major, in 1986 notoriously blamed the ignorance of the people of the North of England for their unhealthy lifestyle compared to the more enlightened South. (Wainwright 1986). Her opinion was supported by studies finding that social classes 4 and 5 were more likely to have high blood pressure and to eat less fruit and vegetables than social classes 1 and 2.
Turrell (1998) would seem to agree with Currie, but from a widely differing political viewpoint; suggesting that health inequalities can indeed be attributed to socio-economic group differences in their dietary behaviours - for example, lack of purchasing power leads to consumption of sub-standard food. In addition, if the socio-economically disadvantaged have less access to health care, this could partly explain their lack of knowledge concerning healthy eating. Further, Turrell agrees that traditional habits can perpetuate negative health behaviours but, unlike Currie, does not absolve government from its responsibility. Townsend, who had been one of the authors of the Black Report, emphasised in arguments with Currie that the shorter life-expectancy and the greater vulnerability to heart disease and other health problems of the people of the North reflected income and wealth disparities between the regions.
As early as the 1970s, it was found that the fewest health resources coincided with the areas of lowest average family income. Tudor Hart’s “Inverse Care Law” proposed that the areas of greatest need had the fewest health services, not least because GPs would seem to prefer to work in more affluent areas, where their practices would receive sufficient funding to develop along the lines they desired. Tuckett takes this to be one of the many contributory factors to the differential use of health services by social classes. He noted that several diseases are class-conscious, with professional classes having only half the expected death rate from them, while unskilled manual workers have death rates at least 50% higher than expected. These diseases include bronchitis, influenza, tuberculosis, pneumonia, epilepsy and hernia.
Studies showed that the higher up the Registrar General’s social scale, the greater the knowledge of the means of transmission of disease, healthy eating and effective family planning methods. Professional class patients were seen to be more confident and at ease in consultation with a doctor and more willing to ask questions, while unskilled manual patients were more uneasy and often waited to be given the doctor’s opinion. Working class patients found it more difficult to communicate their problems to doctors who they saw as middle-class. They therefore required more consultations but each lasted for a shorter period than their middle-class counterparts.
An understanding of the inequalities in health and healthcare is important for nurses, who need to understand a patient’s social condition in order to give the best healthcare. “The patient’s social history, so often of vital importance, is often diminished to a few questions about alcohol and tobacco.” (Hope et al. 1989a). Through education and persuasion, nurses can influence the behaviour of many people who use their services. Therefore acknowledging that a little extra effort may be needed to gain acceptance from someone of a different social class is vital. It is important “to put the illness in the context of the patient’s life.” (Hope et al. 1989b). From my own experience on a cardiac ward, those patients from lower social classes are generally less well-informed about the procedure they are about to undergo and less concerned about subsequently changing the behaviour that has been a factor in the development of their condition, especially smoking and poor diet. Nurses can also influence policy through their participation in the actions of their professional organisations.
Research publicised by the Joseph Rowntree Foundation suggests that some 7500 deaths of people under 65 years old, could be prevented each year if inequalities in health were reduced to the levels of the early 1980s. 2500 of these deaths would be prevented if full employment were achieved. (Rowntree, 2000) However, studies such as this, blatantly demand a redistribution of wealth and there does not appear to be the political will or indeed the public support needed to implement such proposals.
These were the areas given highest priority by the Acheson Report.
“All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities.” Appropriate ways of monitoring the impact on health inequalities should be developed for activities in a range of sectors, such as transport, housing, education, taxation and the benefits system as well as the healthcare system.
“A high priority should be given to the health of families with children.” This will not only help with immediate problems of maternal and child health but may help reduce the longer-term risks of adult chronic illnesses such as bronchitis and coronary heart disease.
“Further steps should be taken to reduce income inequalities and improve living standards of poor households.” Inequalities in health are ultimately caused by social inequalities (in income, wealth, education and other life chances). The focus should be on these rather than the immediate short-term risks that are manifestations of an unequal society, such as obesity, high cholesterol, poor lung function or early and unplanned pregnancy.
“Major gains will be derived from those health problems which occur most frequently.” However, “Policies which improve average health may have no impact on inequalities.”
Unlike the Black Report, which was largely dismissed by the government of the time, the Acheson Report was generally well-received, in that it attempted to find commonality between differing approaches to the reduction of health inequalities and was compatible with government policy.
Following Acheson, the NHS Plan of July 2000 showed a commitment to substantial investment required to modernise the NHS. It included a chapter on Health Inequalities, focusing on public health interventions, access to services and the distribution of the benefit of new investment.
In February 2001 two national health inequalities targets were announced. These were to reduce by at least 10%, the gap in mortality between manual groups and the population as a whole and to reduce by at least 10%, the gap between the geographical areas with the lowest life-expectancy at birth and the population as a whole. These proposals were important, as they emphasised the inequalities in major causes of premature death and the differences inherent in both social classes and disadvantaged communities.
There is no doubt that among all the literature appertaining to health inequalities in Britain, the Acheson Report of 1998 has been the most influential. There were several major impacts of the Report. Firstly, it prompted new government policies and introduced a health inequalities “dimension” to current policies. Secondly, it promoted a climate of opinion that was favourable to the reduction of health inequalities – arguably for the first time. Thirdly, it acted as a work of reference, providing information and recommendations that would stand as evidence that specific action was necessary.
Social inequalities in health and healthcare exist in Britain today and have widened in the last twenty years. These inequalities have been highlighted by several reports, notably Black and Acheson, but only recently has there been the political will to take action. Recommendations include improvements to healthcare and its availability for those who need it most. Education and the curtailing of health-risk behaviours are also of vital importance. Another key factor is the redistribution of wealth, but this is an area that requires not only political will but also public approval. In Britain today, this is unlikely to be forthcoming and the driving force needs to come from government and health professionals, so that improvements in health and healthcare are achieved for the benefit of those most disadvantaged by the present inequalities.