Where to begin?

It's not an elegant or witty title, but it accurately reflects my reaction to the fascinating and wide-ranging views and debate that Gabriel Scally, Alastair Campbell and David Halpern have ignited with their respective takes on what we need to do differently on inequalities in health and wellbeing.

This tremendous breadth also shows why it can be so hard to get a grip on public health, and particularly inequalities. Not only are inequalities pervasive, they are varied in their causes – both ultimate and proximate – and there is no single,  correct way to measure, assess, or reduce them. All of this can lead to an understandable frustration at the lack of progress, a casting around for scapegoats, and a political schism on what to do to address them.

But in my view these blogs, and the reactions to them, can point us in the right direction. In particular, we need to realise that inequalities affects us all (as the Marmot Review showed), as does Alastair Campbell in his blog on mental health, we can all suffer, regardless of our position in society. But we also know that many mental health problems are closely associated with the tough economic times that we are in. Governments should therefore accept they have real responsibilities to shelter and support our health and wellbeing as they design their economic and public policies. That's why I – like many others – see the scrapping of the sub-Committee on Public Health as the wrong decision. Getting health into all policies – and taking account of the effects – will be more difficult without it.

But David Halpern's blog on the potential for nudge shows how government departments and agencies have the power to massively improve our health and wellbeing by also encouraging small and easy changes – if only they would take the time to think differently.  Nudge clearly has the potential to improve inequalities in health, but so have many other well-meaning policies that have just ended up exacerbating them. It would be great to see an analysis of the impact of David Halpern's unit in the areas they are working on with the Department of Health and beyond.

And, as Gabriel Scally argues, it is not only  governments who should be responsible for thinking differently – acting on the big and the small levers, and supporting us as individuals. The NHS is one of the largest employers in the world with massive economic power; its workforce, if mobilised, can bring about huge amounts of change. That's why it’s good to be reminded of, and recognise, the Institute for Health Equity’s upcoming work with the medical royal colleges, BMA and many others to deepen and develop the NHS's role in tackling the wider determinants of health.

I think we can bring about most change first and foremost as principled pragmatists: taking, testing and evaluating ideas from wherever they come – be they from the right or the left – and from structural and regulatory solutions through to nudging. The existing science can to some extent help us sift and sort the things that are most likely to work in particular situations – but we need to become much better at generating, testing and sharing good, practice-based evidence. We also need to be braver about stopping what doesn’t work and spreading what does quickly and systematically. This would be a good place for Public Health England to begin when it takes up its critical role in April.

See more of our thinking on improving the health of the nation


#40054 Michael Crawford

There is an elephant in this room.

David buck talks about the inequalities in the incidence and prevalence of health in society and how these might be reduced but he does not mentio the immediate, huge problem of inequalities in access to appropriate care.

People who reside in deprived localities are less likely to have joint surgery .

People who reside in deprived localities are less likey to have their cancer treated, especially if it is difficult to diagnose.

People who reside in deprived localities are more likely to die from cancer in the first coupole of years after diagnosis.

Specialist services for cancer have been subject to policies of centralisation for half a century. People who reside in deprived localities are less likely to undergo thoracic surgery or to receive radiotherapy. Might these two facts be connected?

Poorer people use the emergency department as their portal of entry to the NHS to a greater extent than their wealthier, more educated contemporaries. Making access to this facility harder is going to worsen the inequality; it is necessary first to make access via primary care easy and acceptable to the whole of society before closing EDs.

The policy of widening the gulf between specialised centrally-provided services and a hotch-potch of community services seems to be destined to increase inequalities in healthcare access. We are in the process of turning the NHS into a Health Service for the Middle Classes.

#40055 Dr Helen Lewis ...
lay representative on emerging CCG
Emerging CCG in Surrey

The other elephant in the room is the impact of having primary care colleagues in a position to determine how a large amount of public is used to meet the health needs of a small local population. Ideas of equity of access appear to have been abandoned, and I am not convinced that we can begin to address health inequalites and major public health issues with the GPs in the driving seat. Even in Surrey we have pockets of extreme deprivation, and the current economic situation is increasing the NHS 'burden' in these areas. We are facing a major reconfiguration of our acute services, and this is expected to demand that local people travel further and pay more to reach their nearest centre of clinical excellence. This will present those with disabilities and/or few economic resources with greater access problems and higher costs than those with more resources.

#40058 David Buck
Senior Fellow, Public Health and Health Inequalities
The King's Fund

Many thanks both for your comments and engaging in this critically important debate. You're absolutely right that the NHS has a big role to play in reducing inequalities in access to, and outcomes from NHS care. The Act places new duties on the NHS Commissioning Board and CCGs directly to do this. We highlighted the access issues, for example the wide variation in good diabetes care, and our view on whether the duties in the Act will be strong enough to counter inevitable variation as the NHS becomes "more local", in the chapter on equity in our recent report on coalition health policy (http://www.kingsfund.org.uk/publications/health-policy-under-coalition-g...). Although no cause for complacency, the NHS does relatively well on access compared to many other health systems (due to a comprehensive primary care system and no, or very low, fees). Where we have been slower to recognise the "power" of the NHS is in its wider role within society, as an employer, economic giant and its reach and connection with all of us through its staff. So, for me there are two elephants and whilst we need to recognise them both, the focus of our blogs here has been the need to start to think differently about the NHS's role in influencing wider society and those things that help determine our health, outside its role as a treatment service.

#40061 Michael Crawford
Consultant Medical Oncologist

I must contradict you on this particularly in respect of cancer.

The international comparisons of cancer outcomes show the NHS throughout the UK, together with the Republic of Ireland, to be doing badly. Further analyses show that this is not because services are deficient once the patient gains access, they show evidence of delayed access to diagnosis.

The point is, the presenting symptoms of some cancers are very vague; there is evidence that the vaguer the symptoms are, the greater the inequality. NHS patient sneed to get access to a GP appointment and then to present their symptoms in such a way as to secure tests or a referral; this requires considerable persistence and articulacy. The GP is required to act as gatekeeper and patients have to compete to allow the gate to be opened for them.

Dr Lewis's perspective from Surrey is very relevant here. The health economy in areas SW of London does not do well out of the funding formula in that the deprived areas are a small part of the total. However demand within that economy is affected by the proportion of patients able to argue their way to receiving appropriate treatment. Residents of those pockets of extreme deprivation will be (are being) thoroughly outcompeted by their affluent neighbours.

Commissioners must be required to look at unmet needs in their areas; they must not simply assume that demand currently recognised equates to need. It may well be that those needs would best be met by a locally-accessible, i.e. decentralised specialist service.

I therefore find your response very complacent; notwithstanding a comprehensive primary care system and no, or very low, fees access to services for some very important but hard-to-diagnose conditions within the NHS is very poor and consequently very unequal.

#40063 Bobbie Jacobson
London Health Observatory

There are 3 fundamental challenges in health inequalities policy:
1. What are the objectives? Improving the health of the poorest fast is this enough? What is poor? Who are our comparators- the richest? The average? Other nations - and more.
2. We will never be able to find current good practice to help us learn from the best because the outcomes are distant in time and are influenced by so many factors . Why can't we learn more from past examples where, over time, inequalitiies have narrowed. Take teen pregnancy where inequalites narrowed for the first time. Would we have allowed teen pregnancy teams to be axed if we had made the effort to understand their role in reducing inequity? Sure Start and early years schemes might be another example.
3. If quantitative and qualitative researchers cooperated a bit more, through smarter commissioning, perhaps we would learn more about how multiagency efforts might maximise their impacts on inequity.

#40064 john Kapp
director SECTCo
Social Enterprise Complementary Therapy compan

To improve, we have to identify the cause, and reduce it. I believe that the cause of health inequalities is that the rich (like me) can and do access complementary therapy, which is denied the poor due to inability to pay. To reduce this, we have to provide NICE-recommended complementary therapy free at the point of use on GP prescription. The Mindfulness Based Cognitive Therapy 8 week course for depression is provided free, but the waiting time for the 160k depressed patients in Sussex is 20 years. To reduce this, the market should be opened up to third sector providers, like SECTCo

#40068 Susan Howlett
freelance counsellor, well-being therapist, researcher, reader
Member of the BACP

Emotional reactions to the way we live in a materialistic world is creating many health problems. It is my belief that to encourage more natural Therapies earlier in life, rather than later. Cutting down on often a life time of medication. Funding for counselling in every School, Surgery, Hospitals and visits to care homes, is needed for staff as well, so they can discuss any problems independently, without fear of losing their jobs, with all the cut backs that are going on. So any emotional dis-ease, does not turn into a physical diseases later on in life.

#40071 Gaurish Chawla

"The GP is required to act as gatekeeper and patients have to compete to allow the gate to be opened for them."

Dr Crawford makes an important point here. One thing we can do is to look at what roles do the GPs can play in facilitating access to care, particularly when the patient is not well educated and not aware of different cancer symptoms, or other diseases.

As David also points out above, the NHS does well on inequality as compared to many other health systems. But perhaps a more important question could be, "What health systems do better on inequality than the NHS, and what can we learn from them"?

Denmark for instance, implemented specialist policies to promote disease prevention and health promotion directed towards the vulnerable groups of society as indicated here


#40073 Titus Alexander
Democracy Matters

Getting health into all policies and taking account of the effects takes more than a Sub-Committee: we need a "Parliament for Health" or National Health Forum to bring together representatives of all stakeholders, particularly patients and democratic organisations of civil society, but also representatives of staff and professional associations and researchers, to maintain a national conversation on these issues and strengthen democratic development of health. At a local level Health and Well-Being Boards also need greater democratic legitimacy and powers to scrutinise the priorities and provision for health including hospitals, primary care and public health to balance priorities in each area. Access to exercise, parks, playgrounds, fast-food, pharmacies and safety att work can’t be separated from decisions about GP practices or A&E services. Each hospital, health centre and clinical service also needs a board with independent representatives of patients and the community. By deepening democratic dialogue about our health and well-being at all levels we can strengthen the relationships and shared responsibility for a healthy society flourish - and address health inequalities in the round.

#40076 Michael Crawford

Recent published evidence adds to my point about access to primary care being an important issue in the UK even thought it has no cost implications for the patient.

The current issue of the British Journal of Cancer has an analysis of barriers to access. A striking one is the fact that patients of the dear old NHS fear that they are wasting the doctor's time; they are 2-5 times more likely to think this than in other countries.


Another paper, not yet in a print edition of the Journal, shows that there is at least some interest in trying to reduce the number of consultaions with a GP that are required to reach a cancer diagnosis.


#40102 Emma Fernandez
Project Manager
Royal College of Physicians

Health inequalities are partly a reflection of how we as people feel about sections of our society. As a society we don't generally like or emphathise with the type of people who are most in need of our services, which in turn has been reflected in long term lack of funding in key areas. Consider how the demented, mentally ill and adolescent patient in our society are cared for by the health service.
This is not helped by lack of any integration across services. I agree with Titus Alexander's comments about discussion across service divides. Having worked in Emergency care, I can tell you that if secondary care is struggling with a difficult patient, so is primary care, the school, the police and social services, but none will be sharing information effectively with each other. Darzi told us this many years ago and we have got no further in making improvements.
Within healthcare we feel safer looking at service delivery issues, time and time again. We do not spend enough time and find it very challenging, to consider how it feels to experience this service delivery. If every healthcare worker spent a day in their patient's shoe's we might make some great improvements.

#40136 David Buck
Senior Fellow, Public Health and Health Inequalities
The King's Fund

The NHS Commissioning Board has just released a consultaiton on reducing inequalities and promoting equality. It would be great if you could share your views and concerns above and make them known to the NHSCB https://www.engage.commissioningboard.nhs.uk/consultation/edc

#40217 neil blackshaw
planning and health consultant
easton planning

Has anybody looked at the NHSCB surevy on reducing “inequalities” ( sic)
I have seen some vacuous management speak in my time but this takes the biscuit. One platitude after another. I cannot imagine how it came about, unless it was a ad agency, or how any seroious person could think it would add value. A truly depressing start.

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