The desire to tackle available, unfair and systematic differences in health has acted as a guide and conscience through my career in the NHS. Sadly, however, as emphasized in a range of recent national reports efforts to reduce health inequalities have been outpaced by societal change, to the point that many regional and socioeconomic differences in health are growing.
As a public health geographer, the 1980 Black Report had a profound impact on me. Complemented by the subsequent Acheson and Marmot reports, the desire to tackle available, unfair and systematic differences in health has acted as a guide and conscience through my career in the NHS.
Sadly, however, as emphasized in ‘The Marmot Review:10 years on’, published in February 2020 and echoed in recent excellent reports from the Kings Fund and The Health Foundation, efforts to reduce health inequalities have been outpaced by societal change, to the point that many regional and socioeconomic differences in health are growing.
This does not mean that efforts have been unsuccessful. Initiatives such as Sure Start and targeted community development initiatives have helped mitigate the worsening of inequalities. In addition, on many measures we are a more affluent, healthier society overall. The truth is, however, that broader factors, including the recent ‘decade of austerity’ and the squeeze on public sector growth – particularly in local authority spending – have countered the positive initiatives to the effect that inequalities persist and in many cases have worsened.
Those living in areas of greatest deprivation live almost 19 years more in poor health than those living in areas of least deprivation – despite also having a life expectancy 8-10 years shorter. Do we still retain the ability to be shocked by this, or, as a society have we accepted this as the effect of different life styles, choices and level of self-control? If the latter, what does that imply for our celebration of ‘the new found community spirit’?
Those living in areas of greatest deprivation live almost 19 years more in poor health than those living in areas of least deprivation
Inequalities have been illuminated by the differential impact of COVID, whereby those individuals and communities with the greatest levels of deprivation have had the highest rates of exposure to the virus, and have suffered more severe outcomes. This reflects continuing structural disadvantage and, for many, discrimination.
The COVID experience, together with the specific experiences of BAME communities highlighted by the Black Lives Matter movement will most probably and rightly trigger a further commitment to tackle health inequalities. It remains to be seen whether this takes the form of a cross-departmental approach, embracing inequity and inequality in education, employment, housing and health, or whether it will be specifically and solely a health initiative.
Whilst the NHS can doubtless do more, there is a need for cross- departmental coordinated action is we are to seriously tackle the wider determinants of health. The roles of education and heightened public awareness are particularly critical as foundations for change.
With regard to health inequalities, what action can the NHS take?
- Clearly there are necessary checks and challenges to better understand the experiences of all minority groups, and most notably, the BAME community, in their access to and use of health services as well as their experiences in accessing equitable employment treatment in the NHS. This has to stretch beyond CoVid experiences to understand and tackle any and all structural unfairness and disadvantage for BAME and other disadvantaged groups, including people with disabilities, the homeless and economic and other migrants.
- Do all emergent health and care systems and organizations have an understanding of the extent of local inequalities? What are the inequalities of greatest concern and what are they doing to tackle such?
- Do all leaders have a good understanding of the most recent Public Health Needs Assessment (PHNA) for the communities and groups they serve? How effective is the PHNA in guiding local priority setting?
- How effectively are local Health and Wellbeing Boards, and other local health partnerships, reviewing and tackling health inequalities?
- Do health and care system plans identify priority, short to medium term initiatives to help reduce local health inequalities? Does this reflect a demonstrable commitment from health and local authority leaders?
- All proposed service changes and business cases for investment must take seriously the requirement to undertake a health impact assessment. How do we ensure that changes will enable access and help narrow inequalities?
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