Reducing inequalities in health: towards a brave old world?

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Unlike in most blogs, here I must declare a potential conflict of interest: I worked in the Department of Health on inequalities in health towards the end of the Labour government and in the first year of the coalition; I was therefore involved in some of what is discussed below.

In the past few weeks there has been a lot of interest in trends in population mortality and life expectancy. Michael Marmot pointed out that life expectancy at population level seems to have stalled, which served as a reminder that there has been concern about trends in mortality rates among older people, in 2015 in particular, but perhaps more importantly over a longer period since around 2010. Public Health England also published its first health profile for England and its interpretation of the mortality trends above.

But here I want to focus on inequalities in health, and what three very recent pieces of information and analysis tell us.

First, at the launch of the Health Profile for England, John Newton (Public Health England’s Director of Health Improvement) presented data that showed there had been little demonstrable change in health inequalities since 2010-12, as measured by gaps in life expectancy and healthy life expectancy by levels of deprivation. 

Second, transparent but buried deep in the Department of Health’s annual report, there lies an assessment of how the Secretary of State is meeting his duties on health inequalities in England. This includes the Public Health England data, but is also a much wider assessment, across 15 indicators from the public health and NHS outcomes frameworks. This data is reproduced in the Table below and shows that inequalities on all 15 indicators have widened since baseline measurement and, for 9 of the 12 for which there have been some mid-point measurements since baseline, the latest data shows widening since that mid-point.

 

Table: Latest trends in public health outcomes framework and NHS outcomes framework health inequality indicators 

Indicator

Inequality by area deprivation (measured by the slope index of inequality*)

Latest data compared to…

 

Baseline

Previous

Latest

Baseline

Previous

Life expectancy at birth – males

9.1

(2010–12)

9.1

(2012–14)

9.2

(2013–15)

Widened

Widened

Life expectancy at birth – females

6.8

(2010–12)

6.9

(2012–14)

7.1

(2013–15)

Widened

Widened

Healthy life expectancy at birth – males

18.6

(2011–13)

18.9

(2012–14)

18.9

(2013–15)

Widened

Static

Healthy life expectancy at birth – females

19.1

(2011–13)

19.7

(2012–14)

19.6

(2013–15)

Widened

Narrowed

Potential years of life lost from causes amenable to health care – adults (per 100,000)

3,165

(2013)

-

3,194

(2014)

Widened

Not applicable

Life expectancy at 75 – males (years of life)

2.8

(2012–14)

-

2.9

(2013–15)

Widened

Not applicable

Life expectancy at 75 – females (years of life)

2.7

(2012–14)

-

2.8

(2013–15)

Widened

Not applicable

Under-75 mortality rate from cardiovascular disease (per 100,000)

106.5

(2013)

103.1

(2014)

109.0

(2015)

Widened

Widened

Under-75 mortality rate from cancer (per 100,000)

103.9

(2013)

103.5

(2014)

105.5

(2015)

Widened

Widened

Infant mortality (per 100,000)

3.0

(2013)

2.7

(2014)

3.1

(2015)

Widened

Widened

Health-related quality of life for people with long-term conditions (health status score)

0.149

(2013–14)

0.150

(2014–15)

0.153

(2015–16)

Widened

Widened

Unplanned hospitalisation for chronic ambulatory care-sensitive conditions (per 100,000)

978

(2013–14)

 

1,009

(2014–15)

1,007

(2015–16)

Widened

Narrowed

Emergency admissions for acute conditions that should not usually require hospital admission (per 100,000)

932

(2013–14)

952

(2014–15)

965

(2015–16)

Widened

Widened

Patient experience of GP service (% reporting good experience)

5.2

(2013–14)

6.5

(2014–15)

7.4

(2015–16)

Widened

Widened

Access to GP services (% reporting good experience of making appointments)

5.2

(2013–14)

6.8

(2014–15)

8.2

(2015–16)

Widened

Widened

* The slope index of inequality is the range between the most and least deprived parts of the population, based on the line of best fit across deprivation deciles. It takes account of inequalities across all deprivation deciles, not just the most and least deprived. Further information on the slope index of inequality can be found in NHS Outcomes Framework Indicators for health inequalities assessment.

Source: Adapted from Table 8, Department of Health Annual Report and Accounts 2016 to 2017. Last two columns are The King’s Fund’s summary of the differences between the point estimates in Table 8.

Looking at this data, you would be forgiven for thinking that there is an unwritten rule for inequalities in health: that everything always gets worse. But, cheeringly, you would be wrong; the third piece of the jigsaw is Barr and colleagues’ important study that sought to discern whether the last Labour government’s strategy on health inequalities – a comprehensive cross-government and NHS-focused approach – had had any effect, as measured by relative and absolute differences in male and female life expectancy at birth between more and less deprived local authorities. Unusually, the findings are cautiously positive. Over the period the strategy was active (late 1990s to 2010), those areas subject to the interventions in Spearhead areas and those more broadly defined as deprived saw a narrowing in the life expectancy gap with the rest of England, reversing the previous trend which reasserted itself once the strategy ended. This finding seems to stand up to a battery of statistical tests and alternative formulations. A study like this can never be perfectly certain because it's about assessing policy with many moving parts, but it is a very good attempt to draw out the overall impact from an extremely complex policy environment for which the authors should be applauded.

This is all the more interesting because by the end of the Labour government it was widely thought that the life expectancy target for Spearheads would be missed, although data lags meant that was never officially confirmed. By the time the data was available the coalition government had dropped the target approach to health inequalities – and the measurement, reporting and supporting mechanism behind it – as part of its ‘bonfire of targets’.

While there were some early signals after the Labour government left office that its approach may have been starting to have had an effect on some measures of inequalities (in particular by reducing within-area inequalities in the Spearhead areas) and our own analysis also suggested some improvement, Barr and colleagues have now looked at this properly and in the round. Their analysis is one that should be welcomed as enormously encouraging by pragmatists of all political persuasions for showing that inequalities in health, in all their undoubted complexity, are amenable to change by policy actions. 

So what, overall, should we take from this seemingly contradictory slew of information and analysis? Well, that health inequalities can be measured in multiple ways in terms of proxies for health, dimensions of inequalities, at various levels of geography and over different points in time. It is therefore possible that different measures will show different things; it’s how they fit together that tells the overall story. 

That story, at least for me, is a consistent one. First, that at population level inequalities in health are persistent and stubborn to shift; the lesson of the past 40 or so years is that will not reduce unless we actively focus on them.  Second, that to shift them we need a multifactorial approach, across government and through the NHS. Third, it also sends a warning: it is all too easy to lose focus, and when you do inequalities in health are likely to widen. Our view of the coalition government’s policy on inequalities in health is that it had little focus, ambition, reach or pragmatism. Since then, in the NHS the approach has been to focus narrowly on important but specific issues around diversity and equality, particularly in its own workforce; while at cross-government level it is hard to discern any coherent and systematic approach to health inequalities at all. In fact there has been no country-level strategy on health inequalities in England since 2008, and the title of this, Health inequalities: progress and next steps, belies its content – it is really an evolution of the 2003 strategy, not a new one. Fourth, that there are significant time-lags in effect, and we need to keep examining the past so that it can be a guide to the future. It is tempting, and understandable, for those in government, those holding the executive and government departments to account (parliamentary committees and the National Audit Office), other political parties and commentators to judge success or failure too early. What the Barr study shows is that when it comes to assessing the impact of policies on inequalities in health we need to take the long view, and we need to value looking back as well as towards the future. Indeed, another important study tracking premature mortality between 1965 and 2015 warns us that the gap in premature death rates in younger people between north and south has recently widened in younger people, reversing long-run trends.

To conclude, we now have the benefit of important new information and analysis which can help us step up on policy and action – both in the NHS and wider government – on inequalities in health. Part of that must be to take stock and to learn the lessons of the past before inventing the future. It’s not just the current government that needs to reflect on this; our assessment of the recent manifestos was not encouraging.

When we plan for the future, perhaps we should bear in mind the words of Aldous Huxley, author of Brave new world, ‘That men do not learn very much from the lessons of history is the most important of all the lessons that history has to teach.’

Comments

Pearl Baker

Position
Carer Independent Mental Health Advocate & Adviser,
Organisation
Independent
Comment date
20 August 2017
I can only speak from my experience as a Carer and Mental Health Advocate. Deprivation, inequality, 'person centred' Health and Social Care, 'Safeguarding' including Housing play a part in the early death of so many Mentally Ill, however the main reason they die earlier than the rest of the population: is the failure of Agencies, including GP who are NOT sufficiently trained in what is required to ensure they do not fall through the 'GAP'.

As a Carer of over thirty years it has only my 'expert by experience' that has saved us, and many others.

Example: 'fit for work' questionnaire is now 50 pages long? you may receive a renewal more than twice a year? however the MINISTERS reply to me is: those individuals suffering from a 'severe disability' will not be expected to complete this form. this is also supported in Hansard, and the Equality Act 2010 where 'severe disabilities are listed.

Example: SDA is no longer a Benefit you can apply for, however if you were first awarded this on a Specific date, you continue to receive this (underlying entitlement).

Example: the DWP send out P60 each year as Incapacity Benefit is TAXABLE, but they fail to identify what is NOT taxable on their P60 ie SDA (non means tested benefit)

Example: PIP replaces DLA many are being denied PIP? to challenge this decision you need evidence to support this Appeal. I Appealed with FOUR pieces of evidence and WON my case.

Example: PIP say if you received a Carers Allowance, and PIP was not awarded, you will NOT be entitled? however their failure to understand you can be a Carer for more than one individual? but only receive a Carers Allowance for one: and NOT at all if you receive a State Pension is just an EXAMPLE of PROGRESS towards 'Deprivation of Carers and the Disabled'.

Example: if you Care for someone in your Home: they are AWARDED PIP, they refuse to Pay them the 'Severe Disability Premium' worth £67 per week. This is currently being challenged.

Example: BUS PASSES were withdrawn from ALL those suffering from Mental Illness in West Berkshire, this was 'fought' under the Discrimination Act, and we WON, however it was for those who were refused to re-apply again?

Example: Dementia resident in Nursing Home are entitled to a reduction in their FEES of £156.20 a week or can apply for CHC, again it is only the 'expert by experience' who can provide this information.

The Examples given above are how difficult it is for the 'severely disabled' to enjoy a quality of life, brought about by those Agencies NOT sufficiently trained in what is required to avoid homelessness, deprivation and 'inequality'.


Gareth Hooper

Position
Project Manager,
Organisation
Gloucesestershire CCG
Comment date
22 August 2017
I think that agencies are working too out of sight of the public knowledge of this issue. I am not entirely sure why that is. Our access to healthcare is reported to contribute around 10% of our health (http://www.health.org.uk/blog/infographic-what-makes-us-healthy ), and therefore it is the 90% that would make more sense to work on. But these big issues are highly political and inherently unpopular. To support those who have the least, resources have to be diverted from somewhere else. A thought might be that those who have the most could be the group to deprive a little to help the most deprived move forward.

We cannot keep asking the NHS and health agencies to bridge the health inequality gap. Adverse Childhood Experiences are a significant predictor of future health, so maybe our resources should be wholly aimed at communities and agencies who directly impact child development?

If we remove health from the inequalities title and replace with 'life' we may risk sounding too philosophical, but this is actually what we should be addressing. Economics and policy should mean that the lottery of life of where we are born or raised, or other external influences are managed and mitigated by good policy. Three score year and ten is what we have to enjoy (more or less, obviously!) and our health is what allows us to do other things that bring us joy, happiness or utility for the more academic of you

So surely our politicians should be doing more to tell the story of what inequality is and bring the population along with them on the journey to equity. A difficult task, I know, but essential if some groups will have to give something up so others can prosper more fairly and equally

Lee adams

Position
Retired dph,
Comment date
22 August 2017
Thanks very useful
The health action zones predates spearheads and did great work in this period unfortunately they were closed down early and the official evaluation was very flawed however local external evaluations were incredibly positive

Christina Marriott

Position
CEO,
Organisation
Revolving Doors Agency
Comment date
25 August 2017
David, This is a really important blog - we need to hold SoS to account for his performance against his legal duty. It is also accurate in terms of the focus required and heartening to see that such focus can lead to changes; kudos to the many people who contributed to the Spearhead work (including Prof. Chris Bentley and, of course, yourself).

But you are right to call out the narrow focus of the NHS at the moment - NHS England fails to understand the difference between diversity and health inequalities, let alone comprehend their intersectionalities. A lack of basic competence in NHS England, including understanding health inequalities and the levers of change in health economies, doom many to early illness and death as NHS England play the EDS 2 fiddle.

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