Health Inequalities – where next. Some thoughts
This is the final in a set of four 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 3 covers the perspectives of a jobbing GP working at the sharp end of this
This one – Blog 4 will cover some thoughts on where next following discussion in Sheffield.
we agreed a Health Inequalities Strategy in 2014, with a clear set of priorities. This strategy is not seen as being wrong as such, but events have moved on and most are are in agreement that the time is right to refresh.
Our current set of priorities are as follows:
• Inequality and poverty are inextricably linked, and should be seen as broadly different lenses on the same broad issues;
• Participation in education and generating aspiration is critical in addressing these, and investment in children’s outcomes is a long term infrastructure investment for economic prosperity;
• Commitment to differential resourcing, or the Marmot principle of proportionate universalism;
• Consideration of the economic impact of inequality, and more broadly of whether a focus on GVA ignores wider social benefits;
• The contribution of building community capacity and power;
• Continued commitment and a clear case for investment in debt advice, cheap credit & welfare rights;
• A clear case for investment in primary care, especially in the poorest parts of the city;
• A desire to support healthy lifestyles by focusing on the environment to make the healthy choice the easiest and default choice;
• A focused effort on CVD risk factors; and
• A refocused effort on the link between employment and health.
Alongside these commitments are ongoing concerns:
• That we have not managed to solve the problem;
• That there is no action taking place; and
• That the issue is just too challenging.
These concerns are set against the impact of austerity on local government budgets and welfare reform, and what they mean for the determinants of health; and met with the response that much activity is taking place.
The purpose of the workshop was to generate a refreshed mission in this context.
Key points arising in and from the discussions
Balancing a medical model against a social model
Although the bulk of the discussion at the workshop focused on areas other than the health & social care system, there remains a tendency to see a medical response as the best way to tackle health inequalities. “Health” is not just the purview of the NHS, and the determinants of health are not the same as inequalities; with this in mind both social and medical models are needed. This is partly linked to it being hard for people to step outside their organisational focus and context and experience.
One consequence of an over focus on a medical model is that too much weight is put on individual level interventions, with less focus on upstream structural interventions that change the context in which people live; this risks exacerbating inequalities.
Contributing to this is the evidence problem: that, if we go with the evidence, we tend to focus on downstream interventions and individuals. This does not mean we should ignore the evidence, because with limited resources we need to ensure value from our investments; but we need to be aware of the issue. In this context the Marmot Report is valuable and still serves as the gold standard in this space.
There ARE individual level & downstream interventions that must be in the mix. The work of Chris Bentley and the work of the Health Inequalities National Support Team is ever green in this space. My view of the critical picture is this one
People understand this, but it is astounding how quick they came back to 1) but tell us what to do, the three big things etc and 2) individual focused and medical model thinking
The short, medium and long term are not mutually exclusive
We need to act on many fronts. Whilst the wider determinants may be the primary cause of health inequalities, tackling these is most difficult and the benefits will be met in the long term. Behaviour change and service interventions are easier, will have short to medium term impact, but the overall impact will be less. For example, we need to help people to secure their maximum entitlement to benefits, but that should not be the end: we also need to tackle the low wage/no wage issue.
In short, the long term matters, and there was commitment in the room to focusing on making “the right decisions for the future”, with the importance of Best Start a clear point of agreement in this respect.
But there was also recognition we have to consider the here and now too, and that doing stuff in the here and now is part of that long term solution: employment and skills interventions and financial security right now are a part of making the kind of households that are good places to grow up in.
In relation to the previous point, how we talk about this matters, and there is much to be built on or learnt from recent work by the Joseph Rowntree Foundation on poverty, the Robert Wood Johnson Foundation on social determinants, and the Frameworks Institute and New Economics Foundation on reframing the economy.
Equality involves a more difficult conversation than we admit
Equality is commonly discussed in terms of levelling the bottom up to meet the top, but in a world of limited resources this may not be possible. As a consequence there may be an important conversation to be had about what those at the top are prepared to give up in the name of equality.
There are no simple pithy answers
There is a tendency to search for simple answers, but no such single pithy answer exists. In many complex systems we’ve made massive strides in some areas by doing the right things well, at scale over a long period. To name a few examples:
1) 30 years ago, survival from leukaemia in childhood was 5% at 5 years; it is now closer to 95%;
2) reducing teenage pregnancies
3) cardio vascular reduction in mortality over the last 25 years
4) smoking prevalence used to be 50%; it is now closer to 15%
All of these were once seen as intractable, but great progress made through the accumulation of small steps over time, and commitment over time. The improvement didn’t happen by magic, they happened because many people did the right things over a long time period and showed great persistence.
Inequalities are arguably more complex, but the same principles can apply
We need a city approach, but this doesn’t mean all activity needs to be dictated and coordinated centrally
The city as a whole matters and this may be where some structural solutions lie. It may be beneficial to draw better links between health inequalities and other workstreams focused on inequality; similarly it may be sensible to make more explicit links to work around poverty.
There is also more scope to join up with discussions on economic development and explore the interplay between that arena and health inequalities. We recognise that economic growth is essential, but it needs to be inclusive, with nobody left behind. We need to make explicit the two-way relationship between growth and wellbeing; more broadly, it may be the case that we underplay the complex interplay of health, wealth, education, poverty and family aspiration and their impact on inequalities.
Beyond this, the economic power of the big anchor institutions in Sheffield is also underplayed. We need to reconsider in context of inequality what role can anchor institutions play in supporting inclusive growth, using mechanisms such as local procurement in this, acting to support aspiration into learning and work through their employment practices.
Recognising that place, services and local context all matter, there is potential for developing a single city approach in this space, aiming to provide the right environment for people to thrive as well as simply supporting them. In doing this we would need to address the challenge of fragmentation between and within sectors, and the challenge of how returns on investment accrue differentially to where that investment is made.
There is also a need to think about what is and what isn’t within the power of the city, both in terms of current or potential new devolved powers. There is a potential role for advocacy to government in this, moving beyond working with what the city is given to also highlight where things need to change at other levels, such as where we need different tools, or policy needs to change, for example.
We should avoid focusing solely on geographical analyses of inequality
There is a tendency to focus on a geographical understanding of inequalities, but this must be balanced by an understanding that inequalities exist for specific cohorts that are not geographically defined.
We cannot expect significant new resource – so we need to figure out how to bend existing resources to the goal
An easy answer to the challenge could be “we just need to invest in x”, but we need to recognise that significant new investment is unlikely to arrive in the short-term. Instead we should focus on the whole resource envelope already at our disposal – the whole economy – and aim to bend it to do the right thing to achieve our goals.
This involves building in the externalities most often excluded from conversations about “the economy”, such as around healthy ageing through the whole life course, and talking about services in terms of investments rather than cost drains.
Further to this, we tend to focus on the money, and the short term. This is understandable, but if we only focus on the money we will do the wrong things. There should be no conversation about money until there has been a conversation about outcomes, and no conversation about outcomes till there has been a conversation about inequality.
Marmot’s message on proportionate universalism is still relevant and still resonates
As noted above, the Marmot report remains the gold standard in this space, but we need to think about this for all of our services, not just the NHS. We need to ask questions like: what does proportionate universalism mean in housing, schools, or early years (to pick just three areas)? What does resource allocation look like now across totality of city – does it mirror the NHS experience of those who need it least receiving the most?
All in the room seemed committed to differential funding. It is clear there is no reverse gear, but if new resource becomes available, or we are reviewing services, we should use a principle of differential gearing to ensure we increase focus on a preventive model and a greater rate of growth in those areas most likely to achieve our stated goals.
We need to know whether we are making a difference
Nobody has the appetite for lots of new data and measurements, but there is an understanding that we need something to understand and capture progress. This may be specific metrics, or there may be mileage in developing a better story and more powerful narrative.
As a starting point, there is a concern that we do not have the right picture of the world: the data we have is probably not complete, and we don’t knit it together fully across the partnership to develop that picture even if it was.
With this in mind, the standard model of performance management will not work or be a good method. It may be Helpful to think in terms of wellbeing (the social model) as the overall framework with good health (medical model) as a contributor. In this context the Happy City Thriving Places Index is considered a good example of a broad set of metrics.
There was agreement that a focus on Early Years is vital
A common theme throughout the discussions was that Best Start and the need to ensure that all children in Sheffield get the best possible start in life, and a commitment to maximising our implementation of this approach, are vital in addressing health inequalities.
Creating aspiration is important
This links to the above point, in that a part and consequence of giving young people a good start in life is ensuring they have aspirations for their futures. However, it goes beyond this as what underpins inequalities is not just lifestyle “choices”, nor poverty of finance, but also poverty of aspiration. This is associated with lack of control (for example over employment or housing); if you lack control then aspiration is gradually and permanently knocked out of you. There is a need to shift blame away from perceived lifestyle “choices” and place it back on society, and argue that in an society with a norm of inequality, aspiration will be impacted.
In response to this we should be building aspiration, and in so doing we will reduce inequality, or vice versa; this could be seen as a deliberate strategy of creating pushy individuals.
There is a need to think differently about localities and communities
All seem to agree that there is a need to do more to empower communities; however what is meant by this and whether there is definitely agreement is less clear. However it is clear that this view should have implications for use of resources; it also lines up with other work that is already underway, such as around the Person-Centred City.
There is a link here to the role of ward councillors, who it was suggested are an underutilised asset in their communities, and represent an untapped asset, source of strength and intelligence that might not otherwise be used.
Linked to this there was agreement that there is a need to engage fully and at length with communities and citizens, – both in terms of what people want (not just now but for the future) and in terms of appetite for rebalancing the way resources are used.
There is a balance between supporting and empowering people, and setting the context straight
The point was made that even empowered people are still not going to be optimally healthy if they live with poor quality air, or in poverty with little prospect of getting skills or a job. From this point of view empowerment is context specific, with structure and broader context still important: in Sheffield 25% of children are in poverty.
There was some discussion of this in terms of shifting the locus of control to the individual or to communities; but also concerns that this could also lead to a shift of the locus of responsibility to the individual, which should be avoided.
What does the relationship between the state and VCS need to look like?
It was suggested that there needs to be a level playing field in this space, and further suggested that there isn’t currently. In response, there was a desire to expose the asymmetrical nature openly and debate it. The VCS will not, by itself, solve the Health Inequalities problem, but it is critically important.
What should we do?
Most agree that it is important to:
1) resist a temptation towards single silver bullet answers;
2) resist single sector answers; and
3) focus on the aggregation and amplification of big and small changes.
Setting in train a vast range of projects in response to the challenge will mean that none of them are done well and that much effort is wasted. Our capacity to orchestrate and execute a set of interventions and programmes that make up any complex system approach is limited (extremely) we need to be realistic on that.
In this space we do know what some of the “right stuff” is, but need to set the conditions for this to be the default; if the conditions are right then the smaller scale activity will follow.
We know we have a (at least) two-fold challenge :
1) To set a clear focus on a small number (no more than five or six) of big ideas that aim to deliver major structural change at the city level. Different stakeholders have (very) different ideas of what that small number of things are.
2) Ensuring that broader conditions are right for others to follow and build on these with smaller scale activity at many different levels – defined by geography and by population cohorts.
And there are important considerations
• Short, medium or long term is not a choice: we need to do all three but not defer starting on long term because there are no near term wins;
• With this in mind there may be a need to develop a method for prioritising actions, considering what stakeholders think we should focus on, and the balance between interventions that open up space to change now (e.g. financial security), interventions that change things now and lay foundations for the future (e.g. employment & skills), interventions that are focused entirely/mostly on future gains (e.g. Best Start);
• There is a case to make health inequalities one of a small number of focus of the refreshed Joint Health & Wellbeing Strategy, in a way that speaks to the city as a whole;
• There is also a case to develop a broad city conversation in this space, looking explicitly long term, and potentially explicitly considering the question of “are those who are doing well prepared to reduce what they get in the name of reducing inequalities?”;
• As part of this, develop an approach around a conversation per neighbourhood focused on “What does health mean to you?”, or “What would conditions would make it easiest for you and your family to be healthiest?”. The Board could seek to maximise the role of Ward Councillors in leading this, and consider the role of Local Area Partnerships;
• Consider how, when all boards and governance mechanisms consider any development, this is done so with the lens of inequality and in particular ensuring this is not a tick box exercise, and consciously focused on the social model and the upstream context;
• There is a need for a visible and emblematic to do list, to ensure tangibles and deliverables are not lost.
• There is potential to look again at the “letter” construct as means of setting challenge to other sectors, agencies or partnerships (such as housing, welfare, economic development) at the local, county and national level, using this as a proposition to focus on achieving health in all policies across many sectors
• Measuring remains an issue. How will we know you are making a difference? What metrics should we use, and how should these be linked to investment plans?