Publication of the Black Report in 1980 brought the first authoritative look at inequalities in ill health and death rates between social classes in the UK. It concluded that these weren鈥檛 the result of differing income, education or lifestyle, but the lack of measures to ensure equal access to health services.
The government of the day attempted to bury the bad news, . Forty years on, and a string of National 91色情片 Service reforms later, socio-economic inequalities in health are still striking. Cancer provides a sobering example.
In 2000, the led to unprecedented investment in people and equipment, and a wide range of initiatives to enhance services. It was a comprehensive and innovative strategy, designed to boost cancer outcomes in England. Subsequent plans 鈥� the in 2007 and in 2011 鈥� reinforced the commitment of successive governments to reduce the cancer burden and improve outcomes for all those with cancer, regardless of socio-economic background.
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Along with my colleagues, I have tried to evaluate the impact of all these plans by asking two questions: have trends in cancer survival improved, and have the differences in survival between the most affluent and the most deprived patients got any smaller? We analysed data for more than 3.5 million people diagnosed with one of the 24 most common cancers in England between 1996 and 2013 ().
Minimal pace of change
Our results update previous evidence that cancer survival in England has been improving steadily, but they also find little sign that these major initiatives had a direct impact. For the 12 cancers for which one-year survival was less than 65 per cent among patients diagnosed in 1996, it had increased by 10 to 20 per cent for those diagnosed in 2013. We set out to find evidence that the pace of change had picked up since the NHS Cancer Plan was fully implemented 鈥� around 2005 鈥� and that was largely lacking.
For leukaemia, myeloma and cancers of the lung in men, and for cancers of the kidney in men and women, one-year survival did begin to improve more quickly after 2006. But no acceleration in the pace of change could be found for the other cancer types.
For cancers of the colon, rectum and prostate, melanoma and two types of lymphoma in men, and for cancers of the cervix and uterus in women, the inequalities in one-year survival between patients living in affluent and deprived areas are now smaller than in the mid-1990s. For the rest of the most common cancers, however, the inequalities in survival are stubbornly similar to those seen in the mid-1990s.
It is important to remember that the survival figures we produced are for all cancer patients in England, not just the 5 to 10 per cent included in clinical trials, where the best available treatment is compared with a new treatment that may be better.
As such, our survival figures reflect the overall effectiveness of the health service in managing cancer patients, including how quickly people seek help for symptoms, how rapidly their family doctor refers them for investigation, whether investigation of the spread of disease is complete, and whether they get prompt access to treatment that is optimal for their type of cancer and the stage at which it is diagnosed. The funding of the NHS and the coordination of cancer services are also crucial issues.
Improving survival for all cancer types, and reducing inequalities, is far more complex than just making new drugs available. It requires a system-wide response: for example with most cancers, prompt and precise surgery and radiotherapy are more crucial to long-term survival than new drugs. This means increasing people鈥檚 awareness of symptoms and giving family doctors the tools they need for timely diagnosis, at a stage when cancer is still potentially curable with surgery.
Target deprived groups
The healthcare system must be readily accessible and easy to navigate, so that all those with cancer receive optimal treatment. Hard-to-reach patients and those from more deprived groups need health policies specifically focused on improving their outcomes.
91色情片 spending as a proportion of UK gross domestic product , but it has increased in other European Union countries. With a growing cancer burden and the NHS under huge financial pressure, raising the survival rate for all cancer patients in England and closing the survival gap with other countries, while reducing inequalities in survival, will not be easy.
Faced with results like these, politicians are fond of saying that cancer survival in England is the highest it has ever been. This is facile: no one expects cancer survival to go down. The real question is why survival for many cancers has not yet reached the levels seen in comparable countries in Europe and North America, and why socio-economic inequalities in survival are so persistent in a health system founded on principles of equity.
Strategies designed to improve public health should be rigorously evaluated to assess their long-term effectiveness. The expected impact on public health, and the measures to be used in evaluating it, should be part and parcel of strategic planning from day one. Margaret Chan, until recently director-general of the World 91色情片 Organization, often put it this way: 鈥淲hat gets measured gets done.鈥�
