Determinants Health In All Policies Inequality Public Health

Why is there a 20 year gap in healthy life expectancy between best and worst in 2018.

In case I need to remind you there is a giant gap in Healthy Life Expectancy.

This is most often expressed in geographic terms, it’s equally important to remember the gap expressed in terms of poor outcomes for those with mental illness, a physical or learning disability.

This blog from ONS highlighted the stalling population level metrics, but skirted over the gap. The ONS data is a huge deal. It’s not a blip.

As many know my approach to health inequality ISNT a health care thing, but a social policy thing.

See the 4 blogs I’ve done in this space here as a reasoning for this bold statement. These cover 1) Reframing, 2) evidence based recommendations on what to do across multiple sectors, 3) some thoughts of a GP at the very sharp end and 4) some reflections on our recent discussions.

It’s not just something that “affects the poor”, it’s a population thing.

It’s also not just an issue that the outcome is confined to Health and Social Care demand, it is a social justice issue & also an economic issue – consider the onset of people with life limiting illness (and the differential age of onset) that definately will affect economic productivity – it’s a two way relationship.

That said, the NHS isn’t off the hook, see this welcome return from Prof Paul Corrigan. In a line – downstream matters still – BP, cholesterol, fags, infant mortality. surprise!!

But……..why does inequality persist

I was asked last week for a simple explanation of why inequalities in health exist still in 2018. In order of importance (least to most) my answer was six fold:

1) Inequity in access to health care.

we all know the system is overly weighted towards hospitals.

Look at the profile of non elective and elective admission by deprivation deciles. Inequity demonstrated.

Look at the split of resource in the health care system between hospital and out of hospital. In itself a determinant of health.

2) inequitable funding within primary care

In primary care some progress toward redressing inequitable funding, but formula still underweights deprivation and overweight age

the demand profile not equitable either. See here on the GP 5 Year Forward View, the importance of inequality and the Deep End.

3) Inequality in exposure to risks

we know a small proportion of health outcomes proportion of health outcomes are attributable to health care. But there is a lot that the NHS can do in this space – guide to medical conditions that are most sensitive to social determinants of health.

Cigarette smoking (c40% in poorest parts of town, 5% in most affluent), obesity, lack of exercise etc.

This could easily be flipped to focus on assets.

4) Inequity in exposure to environmental and social issues – aka “the determinants of health”.

Air quality, school readiness & educational attainment, poor quality housing etc. See here, for example on the Role of anchor institutions in sustainable economic growth, here onPlanning, Adverse Childhood Experiences, Housing, All these have inequality issues inherent in them.

5) Of note austerity policy is differentially affecting core cities compared to Shires. This further weakens the council ability to 1) ensure a safety net  and 2) invest in services that determine life chances (and thus health)

6) Most important = basic predominant belief in an economic system based on trickedown economics.

The wealth creators spread their wealth and the rising tide lifts all boats etc.

Alluring hypothesis. The evidence doesn’t bear it out.

Hence the big gap

2 compounds 1

3 compounds 1 & 2


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