Have we lost the battle to improve health inequalities?

Public health

Health inequalities have ceased to be fashionable. From a position where the goal to reduce inequalities was a core objective of the health system – with national targets to reduce them by 10 per cent – we have seen it steadily marginalised. In a few short years the goal of social equality in health has been reduced to trying, not very hard, to ensure decent access to health care for those in the most disadvantaged groups.

The mandate from the coalition government to the NHS Commissioning Board does mention inequalities five times, but the subject isn’t mentioned in any of the outcome areas and there is no hint of what the government expects the NHS to do to reduce the profound health inequalities that have been so well described and documented over the past decade. The recent abolition of the short-lived Cabinet Subcommittee on Public Health (due to a reported lack of interest from other government departments) does not bode well for the sort of cross-government working that is clearly necessary for the reduction of health inequalities.

In the foreword to his landmark 2010 report Fair Society – Healthy Lives, Michael Marmot wrote 'the more favoured people are, socially and economically, the better their health'. The report identified that children and young people should be the highest priority if we want to reduce health inequalities. There is little that the NHS can do by itself to reduce inequalities, but it could do what it has never done before and exert its societal authority as a collective organisation for which the English population has enormous respect.

Imagine the effect if all the paediatricians, GPs and health visitors campaigned actively in every constituency to reduce childhood obesity. 38 per cent of primary school children travel to school by car in England; a campaign to make it safe for every child who lives within half a mile of their primary school to walk or cycle instead could have major benefits. Not just for children of course – liveable towns and cities with walkable streets would deliver benefits for everyone, particularly in reducing the isolation of older people. It would also reduce the 13,000 deaths from air pollution every year. It is of course the poorest families that live in the worst environmental conditions so the benefits would particularly accrue to the most disadvantaged.

There is little doubt that the leading cause of health inequalities is smoking. We have done well to reduce smoking, but the rate has levelled off at about 20 per cent of the population. The key task now is to halt the recruitment of new smokers. Tobacco use is a paediatric epidemic, and if we can stop the tobacco industry gaining new customers then smoking will go into inevitable decline. NHS smoking cessation services won't give us our first smoke-free generation, but a gloves-off war on the tobacco industry might.

The health professions have led the fight against tobacco, rallied for seat belts and crash helmets and spoken out against alcohol abuse. It is but a step – admittedly a big one – for us to take up the cause of children and young people in bold and innovative ways. But we need new thinking if we are to reduce health inequalities. Where will this come from at a time when the NHS is being turned upside down by an unwanted, unneeded and deeply unpopular re-organisation? Can we add health advocacy to the duties expected of health professionals and a social conscience to the attributes of NHS trusts?

At the close of the foreword to his report Michael Marmot quoted a prescient line from Neruda's collection The Captain's Verses urging action 'against the organisation of misery'. If ever there is a time for collective action it is surely now.

Comments

The NHS has to face several major issues when dealing with inequality.

The first is naivety about cause and effect. Poor people typically have worse health and, historically, this has led to much more NHS spending in poorer areas. But the NHS has little influence over the causes of inequality and the spend does little to reduce inequality. And the extra money also shows a poor return on investment in improving health.

Secondly, Assuming that health inequality is an NHS problem may actually distract from useful investment. Some people have argued that housing quality is a major cause of poor health. So fixing social housing might give ten time the return than the same spend by the NHS. Or adopting a planning policy that drives down the cost of land and housing thereby making good housing more affordable even without much government spend.

Third, all public health policy has to confront the fact that the ability to coerce people into acting healthily is limited in a free society. For example, We cannot stop people choosing to smoke (and it is naive to believe that people only smoke because an evil industry has persuaded them too, after all we have never advertised illegal drugs yet they are as used as tobacco). Maybe free societies have to live with some inequality because different people make different choices.

Government does have some duty to make sure children are not locked into choices by their environment or their parents. But we need to have a much better idea about cause and effect. Maybe the highest impact would be an education system that promotes social mobility, or policies on housing designed to enable anyone to move job and home easily rather than one designed to make the already rich even wealthier.

Gabriel Scally makes welcome and important points. None more so than to stress that we must do more to ensure that the devastating waste of life and health we see across England becomes a central national Government Priority and far greater focus of activities. All too often good intentions about tackling health inequalities slip off political priorities. The difficulties and supposed costs of reducing health inequalities, which have their origins in wider social, environmental and economic factors, overwhelm even the best intended.
The Institute of Health Equity are, in March, launching a report and programme of actions, building on commitments made by medical royal colleges, BMA and others to deepen and develop the NHS role in tackling wider social determinants of health. We hope that this will contribute to efforts to tackle health inequalities and to build the necessary momentum and advocacy to get greater national government action. Public health, employers, schools, children centres, housing, planners, transport teams, we need you too.

Given that tobacco is mentioned here, and obesity has been in all the papers in the last couple of days, it’s worth pointing out that social inequalities also play a very significant role in relation to alcohol harms. According to recent research by Health Scotland, alcohol-related acute hospital discharge rates in the most deprived areas were 7.6 time higher than in the least deprived quintile. Crucially, this is despite the fact that levels of consumption are similar across the social spectrum – indeed, according to most measures, generally lower among the less well off.

The reasons for this remain very unclear. It is undoubtedly tied to the other drivers of health inequality that have been mentioned elsewhere: poor housing, diet and so forth. However, there are other possible causes: different patterns of consumption, different levels of health care, or even harmful drinking exacerbating poverty. It may also be that different social groups report their consumption differently. We don’t know for certain, and yet understanding this paradox is critical to developing effective policies and interventions.

Over the next two years, Alcohol Research UK are funding a flagship research project with the North West Public Health Observatory investigating this issue. It is hoped that the findings will go some way towards explaining this phenomenon. The relationship between alcohol, deprivation and health cuts across some of the most pressing public health challenges, so understanding it better is critical.

Health inequality is not helped by current Dept. of Ed policy. The focus on child health and wellbeing has been allowed to slip and support services for schools have reduced with it.
Much of the hard fought gains by the Healthy Schools programme et al have been lost. This leaves disadvantaged young people in a much worse place for the future.

Gabriel Scally is spot on. The government's rhetoric about tackling health inequalities is daily undermined by its actions on welfare benefits, housing and taxation as well as health service delivery. But it's not just about socio-economic inequalities - those linked to race, disability, gender, etc are also critically important. In my field, men's health, over 40% of male deaths are premature (under 75 years) compared to about a quarter of female deaths. Men are 60% more likely to develop and 70% more likely to die from a cancer that can affect both sexes. Statistics out this week show that male suicides remain at three times the level of female suicides, and that male rates are now rising again. All these inequalities need to be systematically tackled by deeds, not words.

I'm currently much in favour of the Community Asset Transfer approach. Give the various communities of residence, themes and interest, the: assets; autonomy; resources; powers; and support, with which they could take on the identification and implementation of fundamental solutions. The 'communities' themselves are often the most informed 'experts' in; what the problems are; where they originate; and what makes them inter-generational and mutually-reinforcing. The whole The health 'professionals' and other producer interests, along with politicians, have been given immense public funding resources for a very long time - and we have arrived at being a society with some of the most acute and unjustified health inequalities among advanced economies. I helped deliver and facilitate a conference on the theme in Glasgow for the RSA Scotland several months ago. The clear consensus was that the various communities were 'up for' the Community Asset Transfer approach - but the barriers lay with many of the health professionals (with honourable exceptions such as Sir Harry Burns), official agencies such as Community Planning Partnerships in Scotland and - above all - politicians at national and local levels. One essential factor in radical and fundamental change will be autonomy for the individual as well as the community in which the individuals resides and/or woks and/or is a service user.

YES I do think we have or will lose the battle to reduce inequalities. To give you a small example,I have attended the my local NHS Trust board meeting held every month for years, am only one of a very few public that attends, recently the timing has been changed which will make it very difficult for me or any of the general public.Winter start time 8.30 Summer start time 10.30 .I explained that to be able to attend now I would have to leave home about 7.30 get two buses and would be unable to use my Bus Pass so I would have to Pay.I also have an eye problem and don't see very well in poor light as such I asked if the timing could be reversed,, early start in summer late start in the winter but no such. Luck inequalities can only get worse under the current situation

The relationship between social ffactors and health is clear and it is interesting that the current government dismisses a proposal from the opposition to link health and social care budgets, with a greater role for local authorities, because it will be "taking power away from doctors and nurses". This is what we need isn't it?

Stephen seems to be heading in a sensible direction in his reponse to this. In a capitolist, democratic society it is not feasible to remove all sources of inequality. The health service shold be focusing on the job of providing well designed, efficient, evidence-based services that are as easily accessible to everyone as can reasonably be achieved. The historic insistence on completely separating functions such as health, social care and education has limited our success in addressing many of the issues that underlie the differences in health outcomes that we regard as inequalities....the small moves toward better integration and reduced barriers across these areas have been drastically insuffient to address the problems. To signficiantly improve health outcomes and move the levels of inequality toward a more acceptible level, education seems to sit at the heart of things. If we improve educational outcomes across the board, it seems probably that we would see concomitant improvements in social welfare, economic success and health....Yet we seem quite content to continuously allow politicians to tinker with the education system rather than promoting and supporting trained professionals to develop evidence-based practice in education. We a content to see budgets for eduation cut and investment programmes in schools and universities reduced or cancelled....Worry about health outcomes, while we fritter away the future of the whole country by standing still and watching as we slide down the international table of educational performance seems disaterously and wilfully ingnorant and foolish. By all means invest in health research and services - of course this is needed, but it will be through raising the educational attainement of the entire population to the greatest potential achievable that will ultimately move us toward improving population health on a large scale....

This is from my (frustrated) perspective as an ex member of the DHs 'Health Inequalities National Support Team' (made redundant on my return to PCT land an alas given no opportunity to share valueable learning from the HINST work) and now an elected member. I am battling to keep it high on the local agenda - motion to Council, constantly raising issues via Scrutiny etc, but it is like starting from point zero. There is no shortage of agreement that 'we need to do something' but very little comprehension of what, and especially in terms of a planned, targetted, evaluated approach. Altough it could be said I have a personal bias, having been part of the HINST team, I do feel Prof Chris Bentley and the rest of our team were really begining to come up with enough examples of measurable impact practice, and frameworks to assist people to focus action plans.

Health inequalities cost lives, limit quality of life and are bad for the economy - in local govt and nationally.