Health inequality: how can reduction become a reality?

Monday, October 27, 2008

The government is determined to tackle inequalities in health, and by 2010 the public service agreement target aims to close the gap in health outcomes by 10%. A multi-agency approach is required – our expert panel debates the issue

The Department of Health National Support Teams for Public Health offer support on key public health priorities to local areas across England, providing relevant, local delivery, focused advice and ongoing support to key local strategic leaders.

We have small, dedicated teams for health inequalities, tobacco control, child- hood obesity, sexual health, teenage pregnancy, alcohol harm reduction and infant mortality. We are all recognised experts in delivery, drawn from the NHS, regions, local government and the third sector. Our style is genuinely supportive but challenging, and recommendations are based on evidence and existing good practice that we use to agree local practical solutions.

Professor Chris Bentley leads the health inequalities team, which has a proven record of delivery as highlighted in 'Health Inequalities: Progress and Next Steps'. This outlines plans to scale up work to reach the 20% most disadvantaged communities (Spearheads) and share our approach and methodology with non-Spearheads.

The team's diagnostic model to improve service outcomes identifies the factors to determine whether a given intervention will achieve its best possible outcome in a given population.

The major lessons for local areas include: make your vision and strategy clear; extend leadership and engagement from the Public Health Department to the whole local partnership; get system and scale right and adjust your workforce for industrial scale programmes; strengthen primary care; in particular, find the missing thousands – those who already have disease or are at high risk but who are accessing services sub-optimally or not at all; raise the bar on performance targets, which often have ceilings of 70-80% but may miss the most vulnerable patients; and finally, capitalise on community engagement activity already going on and utilise population intelligence.

Cathy Hamlyn, Director of National Support Teams, Department of Health

In East London, half the population is non-white and levels of deprivation, morbidity and mortality are amongst the highest in the UK. Assessing inequalities by age, sex and ethnic group in the management of common chronic diseases and developing strategies for reducing them may contribute to improving health equity. The Health Equity Project is funded to provide practice-based information on equity of disease management and treatment by age, sex and ethnic group for people with Coronary heart disease (CHD), Chronic obstructive pulmonary disease (COPD) and diabetes. Practices can then compare their performance for key indicators for equity of provision. The project also aims to promote self-management courses and embed them in the patient care pathway. The project will promote and evaluate these generic and disease specific self-management programmes in Tower Hamlets, and is based in the Clinical Effectiveness Group, part of the Centre for Health Sciences, Queen Mary University of London.

In the preliminary analysis of 2007, data of 151 practices based in Tower Hamlets, Hackney and Newham PCTs (population 817,927) provided details of chronic disease registers with measurement of key disease variables and prescribed medication, by age, sex and ethnic group. For CHD prescribing, rates were highest in South Asian people and were lowest among black people in comparison to white people. There is also evidence for less than optimal prescribing for all CHD drugs in women and at older age groups. In COPD, patients' smoking rates are higher in white people than in black people or South Asian groups. Among people with diabetes, mean HbA1c (%) was significantly higher in black and South Asian groups than white people.

There is evidence of inequalities in chronic disease management by age, sex and possibly by ethnic group. Comparisons within and between practices may provide useful data for assessing inequity of provision at a local level. Next steps: individual practice audits of health equity and facilitation of the reports. Our programme will work with practices to reduce their differences by linking self-management programmes to disease pathways.

Dr John Robson, Principal Investigator/Clinical Lead; Ellena Badrick, Health Equity Research Fellow, Centre for Health Sciences, Queen Mary University of London

In the most simplistic sense, health inequalities are a consequence of social injustice – they are manifestations of socio-economic variations where the greater the variation in the social determinants of health such as edu-cational attainment, housing quality, employment status and net weekly spending power, the greater the health inequalities gap is likely to be.

In Portsmouth City, for instance, two children born side by side, on the same day, in the same hospital and delivered by the same midwife have vastly different life expectancies – one can expect to live up to eight years longer than the other simply as a consequence of who and what their parents are and the fact that they live two miles away from each other in different electoral wards in the city. It is in a way the ultimate example of a postcode lottery in health.

We can see these same inequalities replicated at a local, regional, national and international level, and the Final Report of the WHO Commission on the Social Determinants of Health, published in August 2008, said: 'Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness and their risk of premature death. We watch in wonder as life expectancy and good health continues to increase in parts of the world and in alarm as they fail to improve in others.'

I could say the same about Portsmouth and about the UK – the three overarching recommendations from the WHO Report are just as applicable to areas of the UK like Portsmouth as they are to wider global communities. The three recommendations are to:
• Improve daily living conditions;
• Tackle inequitable distribution of money, power and resources;
• Measure and understand the problem and assess impact of action.

Social injustice and the resultant health inequalities are no more inevitable than they are desirable. Directors of Public Health must ensure that they use the new power of their joint appointments to both local authorities and primary care trusts to identify the issues relating to the social determinants of health in their Joint Strategic Needs Assessments and then drive forward change through Local Area Agreements using Local Strategic Partnerships as the platform for reform. Ill health is the business of the National Health Service but wellbeing and health inequalities are everyone's business.

The changes that are championed must be powerful enough to improve the daily living conditions for the more disadvantaged communities and will inevitably require the redistribution of money, power and resources in order to deliberately and selectively target the deprived areas. This will require considerable political will and courage to effect the changes and sustain them.

If Directors of Public Health collectively retreat into, or get sucked back into, the comfort zone of the NHS as part of world class commissioning and either miss or duck the opportunity to champion social change, thereby avoiding all the uncomfortable challenges that go with that territory, then we will undoubtedly improve health but we will almost inevitably see health inequalities widen and we will have failed our local communities.

Dr Paul Edmondson-Jones MBE, Director of Public Health, Portsmouth City, and Honorary Secretary, the National Association of Directors of Public Health

The poor health of the poor, the social gradient in health within countries and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate circumstances of people's lives – their access to healthcare, education, their conditions of work, leisure, homes, communities, or cities – and their chances of leading a flourishing life.

Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.

The Commission on Social Determin-ants of Health, Chaired by Professor Sir Michael Marmot, was set up by the World Health Organization to marshal the evidence on what can be done to promote health equity in low, middle and high income countries and to foster a global movement to achieve it. Traditionally, society has looked to the health sector to deal with concerns about health and disease. But the high burden of illness responsible for premature loss of life arises in large part because of the social determinants of health. Action on these issues must involve the whole of government, civil society and local communities, business and international agencies. Policies and programmes must embrace all key sectors of society, not just the health sector. That said, the health sector is critical to global change. It can champion a social determinants approach at the highest level of society, demonstrate effectiveness through good practice, and support other ministries in creating policies that promote health equity.

The Commission calls for closing the health gap in a generation. The knowledge exists to make a huge difference to people's life chances and hence to provide marked improvements in health equity, but action must start now.

Dr Sharon Friel, Department of Epidemiology and Public Health, University College London

The government programme to address health inequalities set Public Service Agreement (PSA) targets in 2001 to improve health outcomes in the fifth of areas with the worst health and deprivation indices ('Spearhead' areas). In order to achieve these targets, however, local agencies need to understand their local inequalities. Although heart disease, stroke and cancers form the leading causes of death, and therefore need addressing nationally, there are significant variations at local level across the country. For example, in Southwark, infant mortality contributes significantly to the life expectancy gap; in Blackpool, however, it is alcohol that is a greater problem. If the London spearhead areas eliminated excess deaths from smoking alone, then the life expectancy gap would be reduced by 37% in men and 30% in women – exceeding the 10% reduction target.

Through the Association of Public Health Observatories (APHO), the London Health Observatory (LHO) developed the health inequalities intervention tool to provide local authorities with the means to both identify and quantify their local problems. As well as identifying the local causes of the life expectancy gap, this tool also models the impact of four interventions known to be effective in improving life expectancy.

Reducing health inequalities can now be achieved by authorities setting local policies to address local needs.

Dr Bobbie Jacobson OBE Director, the London Health Observatory

With 99% of the population living within 20 minutes of a pharmacy, we have an ability to reach patients in accessible locations – at times more suited to their lifestyles – with highly trained staff, trusted to provide quality services, to improve public health, and to address health inequalities. Pharmacies are located close to where people live and work. It is this location of pharmacies in deprived areas that gives the biggest opportunities for pharmacists to work with their communities to address some of the health inequality issues.

The Pharmacy white paper 'Pharmacy in England: building on strengths – delivering the future' lays out plans for community pharmacies as healthy living centres, delivering minor ailments services. Pharmacists help to prevent illness through screening for vascular disease and sexually transmitted infections and can provide more support to people with long-term conditions, with routine check-ups and monitoring.

Pharmacies can deliver a range of interventions such as smoking cessation, vascular health checks, obesity management, etc. These are targeted at the local community the pharmacy serves and can often reach those who either are not yet ill or find it hard to access healthcare. The staff employed in the pharmacy are often local and people in many cases find it easier to talk to people from their own community.

Health inequalities can be reduced, but it needs to include the pharmacy as part of the effort.

David Pruce, Director of Policy, the Royal Pharmaceutical Society of Great Britain