Last year we marked the 75-year anniversary of the NHS with staff shortages, care backlogs and reduced capacity across the service. As the NHS struggles to keep up with demand for health and care services, it is becoming clear that prevention could play a key role in improving NHS capacity, reducing delays to treatment and care and helping people across the UK to live longer, healthier lives. A big part of achieving this will be tackling the health inequalities between affluent parts of the country and more deprived areas.
Spotlight asked experts across the health sector on how best Wes Streeting, the Health Secretary, should tackle health inequalities.
The NHS is taking its responsibilities seriously
Bola Owolabi – GP and director, inequalities improvement programme, NHS England
The stark reality of health inequalities in England was highlighted once more in Lord Darzi’s recent review of the NHS. These are big and complex challenges, which need more than quick fixes.
It is a founding principle of our NHS that no one should be left behind or excluded.
The NHS has identified priority clinical areas for adults and children, where we need to accelerate improvement among the most deprived 20 per cent of the population plus others who experience lower than average access, experience or outcomes.
There are brilliant examples of the NHS developing local innovations to promote more equitable health up and down the country; a mobile dental clinic in Suffolk managed by the local council to assess, treat and give advice to vulnerable children and young people, including those with learning disabilities or who live in care.
Secondly, asthma-friendly schools and youth clubs in Birmingham that provide all children with asthma with a personalised plan, building understanding of the condition among teachers, parents and fellow pupils while playing their part improving local air quality.
Third, a social enterprise improving GP registration among people living in temporary accommodation across Bristol, North Somerset and South Gloucestershire, also offering vaccinations, blood tests and information about wider health services.
Crucially, each of these shows the NHS working across traditional boundaries – hand in hand with local councils, charities, community groups or other strategic partners.
For the NHS to help address longstanding health inequalities, we must continue to make this a collective and collaborative mission.
Only by doing this can we realise our vision – exceptional quality healthcare for all, underpinned by equitable access, excellent experience and optimal outcomes.
We can’t close inequalities with austerity
Sir Michael Marmot and Jessica Allen – Director, and deputy director, Institute of Health Equity and University College London
The poor health of the poor is shocking. Men living in the vicinity of Grenfell Tower had a life expectancy 22 years shorter than those living in the rich part of the Royal Borough of Kensington and Chelsea. Let us take a moment to think about the health of people living in the least deprived areas. Health follows a social gradient – the greater the deprivation, the higher the mortality rate. If everyone below the top 10 per cent had the low mortality rates of the best off over the decade from 2010, there would have been 1 million fewer deaths. Excess linked to deprivation amounted to 148,000 more than would have been expected in the previous decade – 148,000 deprivation-related deaths, plausibly linked to austerity.
This scale of excess mortality cannot be explained by the crisis in the NHS, important as that is, but is closely linked to the social determinants of health – all affected by austerity. To give one example, over the decade from 2010, central government support to local government was reduced by 59 per cent, in regressive fashion: the more deprived the area, the greater the reduction.
That would suggest that to reduce health inequalities, austerity should be reversed. It should. But, in the meantime, there is much that can be done. In 2012, Coventry declared itself a Marmot City. Our 2010 Marmot Review had six domains of recommendations: give every child the best start in life; education; employment and working conditions; minimum income for healthy living; healthy and sustainable places including housing; and taking a social determinants approach to prevention. Coventry took these as the basis of cross-sector action involving the city government, health and care, the voluntary community and other public sector organisations. By the end of this year, there will be 50 Marmot places.
We have the evidence. We have the examples of good practice despite the paucity of funds. Now national government must come behind these hopeful, inspiring initiatives,
Give local government resources to intervene
Greg Fell – President of the Association of Directors of Public Health, Sheffield Council
Improving the nation’s health will require much more than NHS reform. Health inequalities are driven by a vast array of factors, including housing, education, employment, product consumption and the environment. In fact, only 10-20 per cent of our health is determined by access to traditional health services. Health inequalities are also often intergenerational, meaning any solution needs to break that cycle by considering the impact these factors have at all stages of life.
With multiple factors involved, there needs to be acknowledgement that it will take multiple solutions. We need long-term plans to create healthier environments that give everyone access to all the things needed for good health.
For example, addressing child poverty is crucial. The government have already made a start, but this work must continue at pace, with input from across both government and the political spectrum. Meanwhile, nearly 89 per cent of deaths in England are attributable to non-communicable disease, largely avoidable conditions often caused by health-harming products like tobacco, alcohol, and unhealthy food and drink, which disproportionately affect people living in the most deprived areas.
The tobacco and vapes legislation would save thousands of lives and do more to reduce health inequalities than any other single piece of legislation could. The government should then apply the same principles to other products like alcohol and unhealthy food and drink so that any products harmful to us or the planet are restricted, regulated, and their manufacturers excluded from policymaking.
The government don’t need to reinvent the wheel. There are plenty of evidence-based solutions which could be introduced quickly. They must invest in public health at a local, regional and national level so that the measures we know work can be implemented on the ground and we can begin to reduce health inequalities both now and for the future.
Primary and community care will be key
Thea Stein – Chief executive, Nuffield Trust
Health inequalities have been a long time in the making – everything we know about what will improve them (let alone eradicate them) says it will take focus and commitment across the whole of government over a significant number of years. It is certainly not just a job for the health services.
Key to tackling health inequalities is the proper resourcing of local authorities. Many are in a critical condition, with budgets that don’t stretch to do all they want or should do. It is local authorities that should be able to make real inroads in tackling inequalities and who hold the public health budget for their area, which by 2022/23 had been slashed by 24 per cent in real terms per head. With sufficient long-term funding and powers to tackle local issues, real progress could be made on clean air and green space, good education, subsidised transport and gyms, safe and warm housing, as well as proper levels of funding for social care for children and adults.
And the government needs to come good on the promise to prioritise primary and community care. One sensible action could be to introduce a combined primary care and community services investment guarantee, boosting the proportion of NHS spend in this area by 1 per cent a year and monitoring the impact of it relentlessly. We need to strengthen general practice and community services to prevent ill health, and improve early diagnosis of conditions like cancer, heart disease and diabetes. The evidence is there. The unswerving political will has to follow.
Boosting health can prop up the economy
Matthew Taylor – Chief executive, NHS Confederation
Britain has a sickness problem. Since 2020, economic inactivity in the UK has risen by 900,000, and now stands at 2.8 million people with 85 per cent of this increase down to those who are not working due to long-term sickness.
Until the start of covid pandemic, economic inactivity rates in this country, whilst high, were in step with similar countries, yet since then we’ve become an outlier. On average EU countries have seen economic inactivity fall by more than 2 per cent; the UK’s has risen by more than 1 per cent.
It does not take a mathematician to work out this is impacting the economy. Yet if the trend could be reversed, our estimates suggest a potential £35bn dividend to taxpayers over five years and that’s just from halving the post-Covid inactivity increase.
For the NHS this could reap multiple benefits. If targeted preventative health interventions help people find or stay in work, they also shore up the case to invest in health services. And as people of working age on average become even less well when they are not in employment, helping people with health conditions to access jobs could also reduce further demand on services.
We need to concentrate resources on the conditions that seem to be the main reason for inactivity, namely mental health in children and young people, and musculo-skeletal conditions, and the interplay between mental and physical health.
The opportunities presented by tackling economic inactivity are huge. We cannot take the gamble of doing nothing.
Learn the lessons of New Labour’s health successes
Dr Jennifer Dixon – Chief executive, Health Foundation
Wes Streeting should implement a health inequalities strategy as part of the government’s health mission. He could use the previous New Labour government’s approach by setting targets. The existing pledge – to halve the gap in healthy life expectancy between regions – is good. He could look at similar for infant mortality and the working age population that are economically inactive due to ill health. The targets could be hardwired into public service agreements as before or with another accountability mechanism, and be transparently (ideally independently) reported to Parliament. Overall strategy must be cross-government, with short medium and longer term goals.
The New Labour approach was successful, with some progress only measurable and apparent after a decade. Crucially there was investment in a wide range of social programmes such as Sure Start, local government and the NHS, all aided by robust background growth in the economy. Autonomy was given to local authorities to design targeted interventions most relevant locally.
There are quicker wins to improve the health of the population without needing much extra cash. A bill curbing tobacco and vapes is already on the cards. The Labour government should confidently dismiss arguments about killjoy nanny statism by arguing it is protecting the public from food and drink pollutants. Drug abuse is wreaking havoc with health in the most deprived areas – implementing the recommendations from the Black Review should be a priority.
This article first appeared in our print Spotlight report on Healthcare, published on 25 October 2024.
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