• Health inequality
• public health policy
• England
• infant mortality
• social determinants
• occupational health
• systematic reviews
• social inequalities
• unemployment

Mackenbach provides a comprehensive and well-articulated analysis of why the 1997–2010 English Labour government's strategy to reduce health inequalities failed.1 This strategy was more ‘systematically developed, better resourced, more stringently implemented and more extensively monitored’ than those of other European countries and lasted for 13 years. Its success or failure is therefore of widespread importance. The key targets of the strategy were to reduce the relative gap in life expectancy at birth (LE) between the most deprived local authorities (called Spearhead) and the English average by 10% by 2010 and to cut relative inequalities in infant mortality rates (IMR) between manual socio-economic groups and the English average by 10% from 13% to 12%.

Using 2008 data produced by the English Department of Health, Mackenbach demonstrates that the strategy failed to meet its own targets as the relative gap actually increased between 1995–1997 and 2008 by 7% in terms of male LE, by 14% in terms of female LE and by 23% in terms of IMR (from 13% to 16%).1 However, Department of Health official data have just been released which cover the period 2007–2009 and 2008–2010.2 3 This presents a more nuanced picture, as while inequalities in male and female LE continued to increase (2007–2009), the relative gap between manual socio-economic groups and the England average for IMR actually fell between 1995–1997 and 2007–2009 from 13% to 12% with a further estimated fall to 10% in 2008–2010 (table 1). The latter represents a reduction in relative inequalities of 25%. The absolute gap also decreased from 0.7 in 1997–1999 to 0.5 in 2007–2009 with a further estimated fall to 0.4 in 2008–2010: an overall reduction of 42%. This suggests that in terms of its own—albeit limited—targets, the English strategy was partially successful.

These improvements in IMR may have been due to the focus on early years with interventions such as Sure Start or the health in pregnancy grant (the former experiencing severe service cuts since 2010 and the latter abolished in 2011 by the coalition government).4 Such interventions may also explain the differences with the LE trend. The new data perhaps also highlight the importance of time lags when measuring the effects of interventions on health inequalities, especially multiple interventions that may result in a combined effect over a period of time.1 5 The new data does not however undermine the main thrust of Mackenbach's thoughtful analysis which shows what was clearly a missed opportunity in England with too much of the health inequalities strategy focused on downstream interventions.1 Mackenbach's overall conclusion—that there is a need to focus on more upstream interventions—is still supported and this should be the bedrock of any future strategy of reducing health inequalities in England or elsewhere.