The “health gap” between rich and poor is truly alarming. And it is growing. The average life expectancy of a man in the lowest social group is 9.5 years shorter than that of a man in the highest social group. Back in 1972, the gap was 5.5 years. The comparable gap for women is 6.4 years now, but was 5.3 years in 1972. Poor people get poorer health services, too. Those in lower social groups are more likely to suffer from heart disease, for example, and less likely to be treated appropriately for it.
However, even if the NHS distributed its services more fairly, this would do relatively little to improve health or tackle inequalities. Far more important are levels of education and income; nutrition and housing; opportunities for exercise; clean air and water; a minimum of hazards at work, at home and in the streets; freedom from fear and stress; strong, affirming relationships and social networks; and a sense of control over life. Getting a job is certainly a far better way to ward off illness – physical or mental – than getting to a doctor.
The Labour government is pouring money into the NHS: it has promised £19.4bn in additional funds over four years to “modernise” the service. Much of it will be spent on recruiting extra nurses and doctors – many from overseas, because there just aren’t enough trained clinical staff in the UK. The government, however, is missing two opportunities. The first is to get more people at risk of ill-health into jobs. The NHS is the country’s largest single employer, with hospitals and clinics often sitting in the middle of employment deserts. This is exactly where local residents are getting ill for lack of work and the hope, self-esteem and opportunities that work could bring them. Thus some of the NHS billions could be better spent on building local skills and developing new routes for local people into health-related jobs.
The second opportunity is to break down the formidable barriers between excluded communities and the help they need to protect their health. It is not enough to hire more doctors and nurses, because the culture of professionalism itself creates a barrier. The status, the uniform, the jargon, the territory, the membership of a privileged group – all throw up a cordon sanitaire. The greater the social and economic distance between you and your local NHS staff, the less likely you are to know how to find them, to be able to communicate with them, or to have confidence in them. And the more likely you are to be put at the back of the queue, misunderstood, misdiagnosed or inappropriately treated.
In any event, health services are geared mainly towards finding clinical solutions to health problems; they do not see the individual in the round and tackle the root causes of ill-health. And when individuals from excluded or minority communities do manage to get into health service jobs, it is they who have to adapt and change, not the culture and practice of the organisation.
That is why I propose lay health advocates for communities most at risk of illness and premature death. These are individuals who live and work alongside the people they are there to help and, importantly, belong to the same community. They don’t cross the professional barrier. They don’t just channel patients into the NHS. They are neighbours with know-how, who enable others to understand how to stay healthy or get well, and how to get help from whatever sources are available. They act as guides and interpreters, and open doors to advice, expertise and services.
There are plenty of examples already. “Link” workers are attached to some GP surgeries, reaching out to people who are homeless or mentally ill. Sure Start workers are trained to befriend and advise other mothers who (like themselves) have small children. In Birmingham, there is a scheme for training “community parents” as lay health visitors, who can offer advice about healthy cooking and eating, encourage other parents to read to their children and help them cope with difficult behaviour. Some are salaried workers, some are volunteers; others are “volunteers-plus”, who earn an increment to their benefit – perhaps the most practical arrangement for rolling out the scheme on a large scale.
What little research there is suggests that this kind of approach can make a huge difference. Studies by the King’s Fund have demonstrated the value of health advocates for minority ethnic communities and refugee groups – helping them gain access to basic health services, training health professionals to deal more competently with minorities, and helping individuals to stand up for themselves.
Almost invariably, these schemes are strapped for cash and always in danger of going under, existing on the margins of the public sector. Often, the advocates are treated with suspicion by health professionals. And there is always a risk, with a marginalised and underfunded service, that the advocates themselves will give help that is less than adequate.
So what we need now is long-term funding to recruit and train health advocates and build up a service in every community where it is needed, and to develop consistent standards across the country. This should improve the opportunities for good health among those who become health advocates, as well as in the communities where they are working. It could even begin to transform the quality of services and the professional culture of the NHS.
Anna Coote is the director of the public health programme at the King’s Fund
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