Report claims poor deprive healthy; Researchers say ill-health among

THE government should stop focusing its medical initiatives on the sickest and poorest Scots, claims a leading think-tank because it discriminates against healthy people.

A new report from the Fraser of Allander Institute says the key government policy of tackling health inequalities is wrong and should be abandoned.

Closing the health gap between the rich and poor is one of the Scottish Executive's main goals. In a bid to reduce the higher levels of smoking, premature death, cancer, heart disease and teenage pregnancies among the poor, the Executive pledged (pounds) 26 million a year for health improvement programmes in deprived areas. These include running breakfast clubs, providing fruit in nursery schools and smoking cessation support in impoverished neighbourhoods.

But, according to the Fraser of Allander Institute report, this approach to healthcare could be "socially divisive, potentially illegal and could undermine the NHS". The authors argue that if those who are health-conscious and therefore healthier get a smaller share of health spending they may turn their backs on the NHS.

"A commitment to equality of health outcomes seems inconsistent with a commitment to healthcare entitlement. In fact it seems to imply discrimination in the provision of healthcare toward those individuals and groups who at present have poor health.

"This kind of discrimination ruthlessly pursued is potentially socially divisive, potentially illegal and could undermine the NHS itself.If groups who are likely to be very health-conscious anyway find themselves having lower healthcare entitlements because of their relatively healthy state, they will withdraw support from the NHS."

It adds: "Readjusting the supply of healthcare resources to those who have presently the worst health will almost certainly reduce the situation of those who at present have the best health. To deny this is to suggest that these individuals presently get no benefit from the health care they receive."

In the paper, published in the Fraser of Allander Institute journal Economic Perspectives, authors Kim Swales of the institute and Hugh McLachlan of Glasgow Caledonian University say improving the health of the poor will inevitably bring down the health of the whole nation.

"The pursuit of health equality almost certainly involves a trade- off in terms of lower average health. The attempt to achieve health equality is likely to be inconsistent with the fundamental goal of equality of entitlement to treatment."

McLachlan added that by concentrating on bringing the health of the poor up to that of the wealthy, medical innovation will be sacrificed.

"We do think that trying to eradicate health inequalities is likely to hold back medical breakthroughs."

Health inequality, they argue, is not a form of injustice that Scots are particularly worried about, nor one that the government should see as its duty to deal with. Whether we live well into old age is more a matter of luck than government responsibility, they say.

"There is little evidence that people are particularly concerned with inequality of health outcomes as such."

The report adds: "Had we been born in Japan rather than Scotland or in Scotland but of richer parents, then we might have had a greater chance of better health and a longer life than we have but this is not a matter of justice and rights. It is a matter of luck. In present day Scotland women live longer than men. Is this fair? We most certainly do not think that public policy should be geared towards the elimination of this gender and health inequality.

"The Scottish Executive is not required to justify or to remove all Scottish social inequalities which happen to occur. Its concern with the distribution of health - something outwith its moral responsibility and, however much it might affect it, beyond its control - as opposed to, say, the distribution of aspects of health care is puzzling.

"The Scottish Executive's philosophy of health policy should, we suggest, be further explained or else abandoned."

But Professor Graham Watt, head of the department of general practice at Glasgow University, insists that this is a theoretical argument which fails to recognise the extent to which health inequalities damage Scotland.

"I think this is ivory-towers thinking which is somewhat removed from the practicalities of the situation.

"In the city of Glasgow men die four years younger than men in Edinburgh. This policy is not about particular individuals. It is about thousands of people. To reduce the argument to this level is to miss the enormity of the health inequalities problem."

Health Minister Malcolm Chisholm said: "The article is based on a false dichotomy. Health services will continue to be provided on a universal basis in accordance to need, whereas health improvement must focus on the underlying factors which cause poor health.

"We want to see lifestyles improved but within a framework which recognises and focuses on the underlying social, economic and environmental circumstances which influence health - a good education, a worthwhile job, a decent home, a clean environment. We want to close the opportunity gap and create a climate where these basic social rights are brought within the reach of all and so allow the health gain to be maximised."

[email protected] www.sandyford.org www.hebs.scot.nhs.uk

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