This is the first in a set of two blogs attempts to describe the story of health inequalities in a town and recent history, why this remains important, what a strategy might look like and how it might be framed.
Blog 1 considers the story in Sheffield to date, framing, context and language, the impact of systematic strategy.
Blog 3 covers the perspectives of a jobbing GP working at the sharp end of this
Blog 4 will cover some thoughts on where next
I’m sorry it’s a bit long and complex ………
1. The story in Sheffield to date
How do we do?
Inequalities in health outcomes in Sheffield are well documented: there is a 20 – 25 year gap in healthy life expectancy between best and worst along the normal dividing lines of deprivation, mental health, learning disability, ethnicity, etc. The Marmot indicators, which outline this in more detail, can be found here https://fingertips.phe.org.uk/profile-group/marmot. They were replaced in 2016 by the PHE Wider Determinants Tool. This includes a “Marmot Indicators” domain. This paper will not discuss these further for brevity.
The current strategy for Sheffield
Sheffield has a Sheffield Health Inequalities Plan agreed in 2014. The plan was lifted straight from the Joint Health & Wellbeing Strategy (JHWBS) and is made up of all the recommendations in the JHWBS that refer to health inequalities. The JHWBS itself arose from the JSNA. It wasn’t something separate and different: putting health inequalities into a separate plan was supposed to make us all focus explicitly on health inequalities.
In retrospect, most seem of the view that it didn’t achieve that objective; something similar could be said of the JHWBS. It’s a little old now, and all acknowledge there is a need to revise or rewrite it. We all know that health inequalities as one of its most important priorities. We mostly accept there are no simple easy solutions.
The Sheffield HWBB has held two recent discussions, in December 2015 and June 2016. The December 2015 meeting focussed on quantifying the challenge, while the June 2016 meeting focused on agreeing a refreshed strategy; building on the 2014 plan. In June 2016 there were five areas of focus, reflecting a need for interventions with a short and long term return:
• Continued commitment to an asset based community development based approach to health and wellbeing
• Continued investment in and commitment to primary care and within this General Practice services, especially in the most disadvantaged parts of the city
• Continued commitment to the principle of implementing effort and change where greatest need is identified
• Refocused effort on the link between employment and health
• When looking at “healthy lifestyles” focus on the environment and make the healthy choice the easiest and default choice.
Clearly these five areas highlighted were not the only answer to the difficult issue of health inequalities; rather, these were the areas where the Board agreed to focus first.
The Board also requested that emphasis be given to the concept of moving from an equal offer to a differential offer with a view to achieving an equitable outcome. This implies a tailored response to greater need. Finally it’s important to recognise the set of things that can be changed at Sheffield level whilst recognising the continuing need for on-going pressure for national change.
It’s not just about deprived geographical communities
A focus on both geography and specific population groups is needed. The geography issue is broadly a point about socioeconomic deprivation, but it is important to note that this is not just about “the poor” but other excluded groups as well. Other important groups include homeless individuals, prisoners, sex workers and people with substance use disorders, to name just a few. Of course, these populations can overlap: for example, substance use disorder is common in other socially excluded groups. There are many other groups with substantially poorer outcomes than the population average.
The Board also identified that specific population groups require additional focus including, for example: children and young people, BME groups, those with learning and physical disabilities and those experiencing mental health problems. This was a specific issue around vulnerable groups of people, including but not limited to the protected groups identified in equality legislation. The advantage of a double and layered approach is that it allows for multiple inequalities to be handled at the same time.
There is a wider context
The three themes of Due North (Poverty and economic inequality; Healthy development in early childhood; and Share power over resources and increase public influence over decisions) are still pertinent. The Due North analysis is essentially a socio-economic one which builds on this to make the case that economic inequity leads to alienation. Due North argued for the need to strengthen the role of the public sector and tried to address the complexity in this by talking to three different agendas (regionalism and government structures, greater transparency of decision making at a local level and collective forms of ownership). Arguably Due North was weak on the role of the community and voluntary sector, especially grass roots community organisations.
There is a much broader context across the city also. The single biggest factor driving the health gap in the UK is the wealth gap. There are also substantial work streams around issues of direct relevance to health inequalities: work on inclusive growth, the Fairness Commission, and SCC’s/City work on poverty, to name just a few. Relevant strategies in other policy domains are in place, but these may be partial and disconnected – financial security, community stability, community coherence – all need to be pulling together.
2. Why it remains important
•Injustice in itself;
•Social cohesion – Marmot suggests that in societies with substantial inequality the considerable gap between the top 1% of income earners and the rest of society threatens social cohesion;
•Important factor in the slowing down of improvements in Life Expectancy and Healthy Life Expectancy;
•HWBB (and the partners involved) has a legal requirement to address inequality in access and outcomes – See here.
•Not addressing demand will lead to costs to the state that are unfunded and storing up problems for the future. This can be thought of as addressing diabetes vs obesity vs the determinants of obesity;
•This is NOT a side issue, it is a population issue. Inequalities are bad for ALL of us – we’re ALL worse off as a consequence. It’s not just about the most deprived. Inequality is a societal issue: when expressed in terms of the economy, inequality is a drag on total societal production. The same may well apply to wellbeing, such that inequality in wellbeing is a drag on total societal health and wellbeing. Societal health and wellbeing is then a driver of demand for services;
•It is not only a public funding issue but public funding is an important social protection and source of investment in things the market won’t provide.
•From an NHS perspective, inequity in morbidity (and multi morbidity) is driving demand, expressed in terms of consequences for the health care system, with a 15 year differential between the most and least deprived in the onset of multi morbidity. We can document this in Sheffield and it is a driver of demand for public services. I’d encourage readers to consider my take on the the most important charts in health care, particularly chart 2, 3 & 4. This is where the demand in your health and social care system is coming from. I’ve blogged on that. A lot. And won’t repeat all that here
3. Why has there been limited to no progress?
Nobody underestimates the difficulty of moving some of these debates forward, because there are no easy or simple answers. Measurement is easy and talk is easy, but concrete progress is difficult. Reasons for this limited progress include:
•There isn’t a burning platform for the issue that everyone aligns around – the money. Whilst there’s a platform around social justice, amongst other things, this is not connected to the demand and resource implications of inequalities; Addressing health inequalities is not seen as mission critical to the business. There isn’t a “business case” clearly written and articulated on it. However, until we sort out wealth inequality there is limited/to no point talking about economic productivity;
•Differential resourcing is very difficult, politically and operationally;
•The wider context is exceptionally challenging. We are facing the most challenging outlook for public services since the 1970s. Pre-Brexit, the signals were that austerity would continue into the 2020s; post-Brexit, no economics textbook in the world says that a decade of uncertainty is a good thing. This has clear implications for public services that are incredibly dependent on the economic cycle. Austerity is certainly making inequalities worse not better, through direct impacts on individuals and the indirect result of cutting the social security safety net. It has been well documented that the impact of austerity is worse in areas that are more deprived (,,).There is also a layering effect of multiple cuts on families. The 40% Local Government cut will and is directly affecting the things that determine health of individuals and communities (such as the closure of Surestart Centres). We can’t keep cutting and expect nothing to happen. It would appear that both quality and length of life is deteriorating as we get deeper into the impact of austerity;
•Beyond austerity, the resource allocation formula itself has created inequality;
•Governance: the current challenge needs stable long term government. We have a minority government: history (1970s) suggests it will last, but that the government will be thinking in days and weeks, not months, years or decades. There is a need for a fundamental realignment of systems but in a minority government, the overriding mind set will be “is it contentious?” Realigning priorities is contentious and thus likely to not happen. At the local level, governance is messy, with differential levels of devolution, financial challenges and limited stability. Grenfell Tower is an obvious and emblematic tragedy and profound in governance terms. It has challenged all of us as we have created an “efficient” delivery system through outsourcing leading to fragmentation where nobody is in control, and leaders have no line of sight and no real control.
4. Language and framing of health inequalities. It matters
There is value in being clear about how we understand and talk about the issue that is health inequalities, including the words and framework we use.
The issue could be Framed around the following domains (not necessarily in order of importance before anyone gives me grief):
•Our health behaviours and lifestyles
•Wider determinants of health
•Communities and health
•An integrated health and care system
The Marmot areas of recommended policy focus remain the benchmark:
• Enable all children, young people, and adults to maximise their capabilities and have control over their lives;
• Create fair employment and good work for all;
• Ensure a healthy standard of living for all;
• Create and develop healthy and sustainable places and communities;
• Strengthen the role and impact of ill health prevention.
It may also be framed around life course (starting well, living well, ageing well) and in terms of services for people and places where people live.
There is also merit in bringing together the various strands around equality, poverty, inequality and similar as many of them cover similar space
What words do we use matter
The language of “health inequalities” might benefit from simplification: Consider the impact of “health inequalities” vs “poorer health and shorter lives”. There is a need for language that communities really engage with. The Robert Wood Johnson Foundation have done some interesting work in this space, as have the Frameworks Institute, specifically here. In discussion with residents, there will likely be a focus on their priorities relating to the here and now. Getting public focus on health inequalities might take some doing.
What framework do we use?Julia Lynch makes the case of the danger of “medicalising” or individualising heath inequalities:
“ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities. Medicalizing inequality is appealing to many, more appealing than tackling income and wage inequality head-on. But it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities”.
Similarly Marmot points out that evidence on “tackling” health inequalities tends to be focused on the biomedical model paradigm and evidential thinking. Marmot recently noted that “downstream” interventions have been covered, for the most part, in the scientific literature. There has been much less focus on structural interventions.
“If one went purely by the numbers of papers published, one would put effort into pharmacological treatment and would ignore housing; emphasise case management and ignore poverty”.
We need to be clear that “Health” does not mean the same thing as “the NHS”. We should define the differences between “Health”, “NHS” and “Social Care” vs “Health” and “Wellbeing”. Using the narrative being promoted by Prof Burns on salutogenesis (what causes good health) vs pathogenesis (what causes ill health) could help.
Determinants are not inequalities and vice versa. The term “determinants” is one way of expressing the risks to health and wellbeing. They are upstream risks, assets or protective factors. Both upstream and downstream factors matter, but we should start from the position that upstream factors matter more. Inequity is the differential distribution of these factors.
Health inequality is therefore about:
1. The unequal distribution of clinical and lifestyle risk factors (a small part of which is about the NHS)
2. The unequal distribution of social and environmental risk factors (the determinants)
3. The determinants of the determinants (power, concentration of wealth, dominant economic model etc.)
Health inequalities are not a “health” thing, or indeed a “public health” thing. The consequences of “health inequalities” are social and specific to the NHS only in terms of demand. Some argue in this context that the Department of Health & Social Care is the wrong sponsor agency, as it is responsible for the consequences of failure rather than the solutions. There is also a danger that DHSC sponsorship will tend to lead to health service design solution thinking first.
The causes are largely upstream of the NHS. There are local, regional and national aspects to the solutions, especially in terms of skilled advocacy and challenging conversations with other parts of government, and the economic, social and political ideologies that make the inequitable distribution more likely: the determinants of the determinants.
5. The impact of a deliberate strategy: is it worth the effort?
From a number of viewpoints. If you don’t care about social justice and important stuff like this, and only care about demand for services and money – I’d encourage you to very carefully consider the last two bullet points in section 2 above. This directly links inequality to demand, and illustrates why it’s not just a soft fluffy social policy issue.
Barr highlighted the positive impact of a deliberate strategy at national level, considering geographical health inequalities measured as the relative and absolute differences in male and female life expectancy at birth between the most deprived local authorities in England and the rest of the country.
The analysis suggests that prior to the introduction of the English Health Inequalities Strategy, geographical differences in life expectancy and health were widening. During the implementation of the strategy, these trends were reversed but since this program ended there is evidence to suggest the improvement is being undone.
The period of the strategy encompassed a time (up to 2008) of increased public spending, economic growth and stability, relatively low unemployment, and increased investment in both healthcare and programs that addressed the wider determinants of health.
There was not always a clear distinction between policies that were part of the health inequalities strategy and policies that would have happened anyway in the absence of the strategy. However, this period of increased social investment across the whole of government, targeted at disadvantaged areas and groups, was associated with a decline in health inequalities and geographical differences in life expectancy.
The end of the strategy and the start of the austerity program which reversed many of the key policies occurred at the same time, and therefore the effects of the program ending and austerity starting cannot be separated out. However, there is clearly a stark contrast between a time when investment in policies which addressed the wider determinants of health resulted in a reduction in geographical differences in life expectancy and health, and the current policy environment which may be reversing those trends.
The reductions in the gap between best and worst were circa 1 year, which is hugely significant given the population nature of life expectancy. Think of the number of life years involved in such a change in life expectancy, then think about the morbidity – and thus lost productivity economically speaking and heath / social care use that preceeds death.
3 See also Liverpool John Moores – Welfare reform, cumulative impact analysis 2017