Introducing the Forum in the context of the Fabian life chances approach, Sunder Katwala noted that the problem of health inequalities was essentially political. While the Conservative discourse around social breakdown enjoys some public resonance, it fails to account for structural determinants of inequality. The government, he said, must articulate a public argument about the disparities in life expectancy between individuals from different backgrounds if it is to win permission to act decisively on the issue.

There was broad agreement with the structural analysis of the causes of health inequality, with factors such as early life experiences, social exclusion, work, unemployment, addiction, food and transport suggested as key determinants of someone's health. There was a recognition that the drivers of health inequality are changing, from cardio-vascular conditions, cancer and heart disease, to drugs, alcohol, obesity, suicide and violence. Representatives of Help the Aged and Age Concern raised the issue of winter fuel poverty and housing inequality – "cold damp homes" – as significant factors for older people, while many participants emphasised the significance of mental health.

Anna Coote suggested this analysis required a shift in health policy emphasis away from its "obsession with making people better rather than making people well". This, she said, might mean "we should spend less money on the NHS and more on housing and education". Many participants agreed that many of the factors driving health inequality fall beyond the traditional remit of health practitioners, not least amongst them, levels of income inequality in society.

However, a number of key barriers for health practitioners to overcome in narrowing the gap in health inequality were identified. The question of access to services and 'middle class voice' was seen as paramount by many participants. Professor Rosalind Raine of UCL highlighted the clinical decision-making process as crucial in this regard. It was felt that more emphasis was needed on the organisational culture and training within the NHS to overcome a lack of congruence between practitioners and patients. The approach of GPs, it was suggested, was particularly important given their role as 'gatekeepers' to the health system.

Sandy Macara agreed that too often professionals' attitudes towards what they see as 'irrational' behaviour, such as smoking or obesity, has been to blame patients rather than seeing them as victims of the food industry or other structural factors. This sense of moral outrage could be seen, it was suggested, in policy towards hard drugs, which might better concentrate on their supply rather than their demand. It was suggested that policy makers and practitioners should be careful with their use of language – referring to someone as 'overweight' rather than 'obese', for example.

Many participants stressed that the importance of mental health continued to be overlooked in health policy debates. The sheer inadequacy of the mental health system and, above all, social stigma surrounding mental health problems and conditions, remains a key barrier to progress on health inequality. Mental health inequalities will be discussed in further detail in seminar four of this series.

Participants also discussed proposals for overcoming these barriers. Julian Le Grand identified two fundamental problems associated with public health initiatives: the time-lag between costs and benefits of action; and questions over the legitimacy of the State to intervene to protect an individual's own health. An approach he termed "libertarian paternalism", he suggested, could respond to these problems by shifting the default position in key areas impacting on individuals' health.

Possible initiatives he suggested were a smoking permit that would make it more difficult to smoke without ultimately preventing people from doing so; a requirement on employers to offer an exercise hour at work, that employees would have to opt out of; and a ban on salt in processed food that would leave consumers to make a conscious choice to add salt should they wish to.

John Wyn Owen called for a modern public health act, suggesting it be called a 'Health of the People Act'. With devolved delivery, this would establish a long-term, sustained framework around the determinants of health, institutionally built into public services across government. This would draw on experience in Sweden where health legislation has focussed on the determinants of health, strengthening control over delivery at a local level, in work places and children's services, for example.

Many participants supported the need for a long-term focus across policy areas. It was suggested that environmental concerns could be incorporated into the health policy agenda, since climate change will have an earlier impact on poorer communities and can be tackled with many of the same interventions as those aimed at health inequality. Better insulated homes, for example, have benefits for poorer communities' health, lowering winter deaths and reducing depression, while also lowering carbon emissions.

It was suggested that changing behaviour, whether to narrow health inequalities or tackle climate change, required greater devolution of power and resources so that projects and programmes could be better tailored and more sensitive to local needs. Participants suggested that PCTs could be integrated further into local government, with joint appointments for social services, for example, and greater responsibility for local councillors for health and well-being. The role of schools and teachers was stressed, with the example given of Finland where one hour of sports per day has successfully been built into the curriculum.

Anna Coote also suggested learning from old ideas such as the Peckham Experiment and health action zones. For devolution to be successful, she argued, extra resources for hospitals and acute care should be transferred to local services and placed in the hands of local people. Sunder Katwala noted, though, that localism should be carefully balanced with central national direction, as local areas will generally be unwilling to jeopardise good quality services in the name of wider health equality. Ring-fencing of budgets was suggested as one possible way around this problem.

Ultimately, tackling inequalities in health was seen to require a clear focus on the status and empowerment of groups and individuals with poorer health. This would necessitate action across a range of, often complex, factors, within and beyond health policy. We should not, though, Julian Le Grand warned, be put off by the seemingly cosmic proportions of the problem, and remember that health practitioners and policy makers, by thinking innovatively, can make a difference.

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