Drop the euphemisms and stop sugarcoating poverty

I have mixed feelings about euphemisms. They can make it easier for some of us to talk about sensitive health issues – think ‘senior moments’ instead of ‘dementia’ or ‘women’s troubles’ instead of ‘gynaecological issues’. Euphemisms can also help us navigate uncomfortable topics and give us a way to broach tricky conversations. But they can also be confusing and often obscure harsh truths.

I’ve previously argued that the NHS tends to shy away from using the term poverty. It seems to be more comfortable talking about the cost of living or wider determinants of health rather than poverty or destitution. There is a silence around poverty – yet it seems strange to be so silent on something that has such a profound and harmful effect on people’s health and happiness, and across generations.

I recognise that it can be hard to talk about poverty, particularly for those experiencing it. It’s seeped in stigma and shame. One way to challenge this stigma is to name it. At The King’s Fund, we have made an explicit decision to name poverty – to try to sit with it and understand its ugly, pernicious, all-encompassing horror.

We are also learning firsthand that talking about poverty exposes you to several risks:

1. It feels political. Discussions about poverty can lead to conflict and disagreement over both its causes and solutions. Current debates about welfare reform and whether it feels appropriate for NHS leaders to speak out about it reveal how hard it can be to speak openly about poverty.

2. It gets technical quickly. It’s easy to get lost in the definitional subtleties of absolute and relative poverty or whether you can substitute deprivation measures for poverty ones. Its complexity undermines confidence to speak out on the issue.

3. It can feel overwhelming. Poverty is one of those ‘wicked problems’ that can feel insurmountable and impossible to solve. It can feel hard to know where to start.

Are there lessons then that the NHS might learn from looking beyond health to other examples of poverty? Think fuel poverty, food poverty, period poverty, child poverty, water poverty. Why not ‘health poverty’?

There’s something appealing about coining a new term and adopting tactics from others who have had success in gaining traction when it comes to highlighting poverty. Health poverty could provide legitimacy and give the NHS greater confidence to lean into the issue more. It could look like food poverty, which doesn’t have an agreed definition but is widely understood to mean not being able to afford adequate food to make up a healthy diet.

But there are reasons why there have been relatively few studies on health poverty as a concept. We don’t have an agreed minimum standard of health that everyone should be supported to achieve or is entitled to. Unlike fuel poverty, for example, where a household is considered fuel poor if it needs to spend 10% or more of its income on energy to maintain satisfactory heating, there is no accepted definition of health poverty.

Also, unlike commodities such as food or energy, there is an assumption that the NHS is free at the point of use. And even though we know that this assumption does not stand up to scrutiny because people on low incomes face significant problems accessing and using the NHS, it means that health poverty as a concept does not align well with other forms of poverty. The costs associated with health poverty feel more diverse and harder to spot, for example having to take time off work for an appointment as well as paying for prescriptions.

And what is needed to keep you healthy – quality housing, green spaces, nutritious food, low crime – remains out of reach for many and goes beyond what is considered to be the remit of healthcare providers.

Given the reasons cited above and the challenge of agreeing any consensus on what good health looks like, health poverty seems an unlikely option to encourage the NHS to better recognise and act on poverty. I’m curious then to know what else might prompt action. I definitely don’t think it’s more data:

• We already know the scale of the challenge the NHS is facing. In England, 1 in 5 people live in poverty and about 3 in every 10 children are growing up in poverty.

• We already have sufficient evidence to show poverty is a key driver of poor health. People living in poverty find it harder to live healthy lives, harder to access NHS services, live with greater illness and die earlier than the rest of the population, and socio-economic inequalities in health in England have been widening since 2010.

• We are not short of solutions. There is growing evidence of what works and many examples of how health systems are working to tackle poverty such as Greater Manchester or Newham.

Poverty and the NHS is clearly a sensitive issue. I think it’s helpful to actually name poverty. It’s not something that the NHS can or should ignore and avoiding the term does not remove its impact, but do I think a new label would help? It’s an attractive idea, and I’m all for stealing ideas from other sectors, but I remain unconvinced. It’s not new labels that are needed to help break the silence that seems to surround poverty in the NHS.

The Joseph Rowntree Foundation’s existing definition of poverty – ‘when a person’s resources are not sufficient to meet their minimum needs (including social participation)’ – is clear and applicable to health. Tempting as it might seem, a new label (and the ensuing debate about how to define it) would only divert us from what we already know works, such as effective leadership, training, effective use of data, and working alongside people who have experience of poverty.