Health inequalities – what to “do”. What are the actions or interventions we should implement?

This is the second in a series. The first blog set out some background, context, language and framing issues. Here I set out some thoughts on intervention. Again, it’s a little fiddly.

1. General principles & Framework

There are a number of different evidence based approaches to what we can do, such as those produced by Marmot, Due North or our own Strategy, to name just three. This needs to be put into a framework, and a decision made regarding how to focus.  See blog 1 for some thoughts.

For example a framework could develop around behaviour, determinants, communities, health and social care.  It could also be framed around the life course (starting well, living well, ageing well), or in terms of services for people and places where people live.  Any serious effort to address health inequalities must start with inequalities in outcomes around employment, income and housing and wealth inequality/ownership of capital.

There are a number of recurrent themes in a discussion  on general principles:

• Resist single silver bullet answers: all domains need answers and solutions. Everyone wants pithy answers: they don’t exist.  Marmot’s recipe still stands and hasn’t been beaten.  There isn’t a single intervention – policy or service wise – that will crack this issue;
• Most are unconvinced that “writing plans” will solve or make much progress. As above, measurement is easy, and talk is easy, but concrete progress is difficult.  Whilst we probably don’t need to measure progress on indicators with ever finer grain detail, we DO need to ensure that implementation of interventions is robustly monitored.  There is something to consider regarding the underlying narrative and whether we really believe it, also something around an organising principle to be hardwired into organisational DNA rather than a standalone plan (while accepting someone somewhere might occasionally need to do something);
• Complex system: one of the things that has hindered progress is the size and complexity of the issue. Progress may depend on the interplay of national and local government policy, with aspirational and practical actions for local players.  In addition outcomes are a complex interplay of health; wealth; education; poverty; family etc.  All interact in ways we often don’t fully understand but all matter, and can’t really be adequately addressed in silos.  This is compounded by the fact that progress in this area is NOT the path of least resistance, especially at times of shrinking budgets;
• Influence by proposition: splitting the agenda into actionable chunks might help but not letting sight of the whole is equally important. Health inequalities are cross cutting not “owned”.  We need to think how to frame cross cutting issues in ways that have traction across and within silos.  This leads to questions such as: What and who do we want to influence?  What do we want in terms of resource, power, and permission?

2. PHE guidance is helpful. System, scale, sustained effort.

Consider those areas that have seen real change. It’s mostly a combination of doing  different stuff better (transformation) or / and sustained effort to do the right things, at scale, over a long time (aggregation of marginal gains).

Recently PHE guidance – reducing health inequalities: system, scale and sustainability – set out a revision of the DH Health Inequalities National Support team work

Key points:

• intervening at different levels of risk – phsysiological (BP, cholesterol), behavioural (smoking), psychosocial. All interconnect. All need attention. Don’t neglect one at the expense of others
• intervening for impact over time
• intervening across the life course – start well, live well, age well. Direct link to Marmot themes.
• to have real impact at population level, interventions need to be sustainable and systematically delivered at a scale in order to reach large sections of the population. Reach and coverage of effective high impact interventions in populations.
• In medical terms most of the gap is made up of CVD, respiratory, Cancer – thus think of prevention in the context of risks for those broad areas,

 Not just service level

• Intervening at civic, community and service levels can separately impact on population health. In combination, the impact will be greater.
  • Civic interventions – through healthy public policy, including legislation, taxation, welfare and campaigns can mitigate against the structural obstacles to good health. Adopting a Health in All Policies approach can support local authorities to embed action on health inequalities across their wide ranging functions.
  • At a community level, encouraging communities to be more self-managing and to take control of factors affecting their health and wellbeing is beneficial. It is useful to build capacity by involving people as community champions, peer support or similar. This can develop strong collaborative/partnership relationships that in turn support good health.

3. Specifics
4. General

Multiple authors and commissions have published many detailed specific and generic recommendations and policy prescriptions.  Each prescription has merit and there is some overlap between different publications, while many of the recommendations are of relevance to national agencies, some to regional agencies, and some to local agencies.  Some of the national recommendations may be localisable (either directly or through devolution).

Some interventions are within SCC control, some are within the city’s control and some are NOT within immediate control.  We should consider “the ask” of our services and policy areas, and what cuts across many services or portfolios.

A simple prescription is not possible, but the following themes are commonly cited:

• Differential resourcing: this is the disproportionate distribution of resources, services and assets to meet disproportionate need (and inequitable outcomes). It is unknown whether the distribution of resources (wrapped into service delivery or otherwise) and assets reflects the patterns of need.  In NHS delivery there IS a mismatch, and the challenge is to disproportionately invest in a generalist offer matched to need levels.  We don’t know the extent to which this story is reflected across sectors within the economy.

This may not ONLY be a debate about “resources” defined narrowly or broadly, but also about the right policy framework and coverage of effective interventions.  In a net zero new cash environment, there may be merit in exploring mechanisms for addressing resource inequity: hold top and level up vs level down vs some other version of how the principle is operationalised.  Whatever mechanisms are used the need is to focus the greatest resources where need is highest, and not disinvest as it is more expensive improving outcomes in the populations with most need;

• Re-look at the economic impact of inequality: GVA vs broader social benefits. Inclusive growth vs sustainable economy.  Addressing inequality is NECESSARY for economic growth.  There will be merit in relooking at the public sector supply chain in this and how well we really enact social value in our commissioning, inclusive growth & sustainable economy, living wage and our role as employer around skills and jobs.  In this area the wealth gap is (by far) the most important, however not easily or quickly resolvable.  This obviously lends itself to the narrative on inclusive growth, and that may be a more effective line to pursue;
• Community capacity and power: some call this “community development”. Some have suggested that the various strategies for community capacity building (PKW, Neighbourhoods and others) are too small, marginal, insecurely funded and not well enough connected.  There may be merit in relooking at how we commission volcom organisations, and what our expectations are of them both in terms of service delivery and in terms of voice and capacity development.  Linked to this, but not just in this domain, is the focus on a needs (the needs of the marginalised) vs assets (scope of opportunity) approach and a greater sense of coherence across areas.  Some of the key issues here are financial insecurity, anxiety about not being in control of where they live (‘social cohesion’) and a cynicism about local services.  Our strategies are a mixture of responding to crisis and jam tomorrow (employment); we often miss out the bit in the middle: addressing current insecurities and vulnerabilities;
• Inequality and poverty are obviously inextricably linked and might be viewed as different lenses on broadly the same issues. All of absolute poverty (not having money makes a difference), relative poverty (the size of the gap between best and worst) and the floor threshold (mustn’t fall below) are important.  On relative measures, we need to compare mean and median income for instance, as both measures can tell different stories;
• There is a clear case for investment in debt advice, cheap credit & welfare rights for those most financially vulnerable, in the context of welfare reform. The welfare budget dwarfs the NHS (£215 billion spent in 2015/16 on social welfare support including pensions, or £125 billion on means tested and disability benefits); it IS a determinant of health and is likely differentially affecting the most vulnerable.  Relatively little effort is put to understanding need in this space; for example, the level of problematic debt among key populations.  The tax and benefit system is certainly affecting child poverty and living standards have got worse for families with kids.  Recent IFS figures projected that the 2015 budget will mean the income for families with children will get worse at a level proportionate with starting income, i.e.  it is regressive making the lot of the worst off worse;
• Participation in education and generating aspiration is important. Investment in children’s outcomes is a long term infrastructure investment for economic prosperity.  “That’s not for kids from round here”.  Kids often have high ambitions until they are 13 or so, then those ambitions are dulled.  The job is keeping them with high ambition through to career.  The opposite is to deliberately create the equivalent of “pushy parents”.  Demanding, wanting the best, articulate a different vision of the future.  Hunger for learning that drives self-esteem and attainment.  There may also be a case to reconsider the pathways into work especially those looked after, care leavers, no qualifications, learning disabled.  The role of multi academy trusts needs consideration.  Some will get this agenda, some may not.  See here – for an example of capacity development across a large number of schools.

1. Evidence base. Health inequalities evidence based policy prescriptions and interventions. What to do?

 This section presents a summary based on available sources of evidence – ie it is evidence led, rather than idea led.

There is no shortage of policy prescriptions and ideas. This document isn’t necessarily complete, many will find glaring holes, thus should be viewed as work in progres

• Effort make to ensure ideas are positive not patronising, life course focused, and focus on structural interventions
• Effort made here to focus on issues with local traction, some national ideas included – become targets for advocacy.
• Interventions need to focus on services for people, places where people live and structural policy interventions.

Considerations in evidence led approaches

One overarching issue common to all the evidence reviews is that upstream policy measures to reduce material poverty and deprivation are crucial to prevent extreme social and health inequalities from occurring in the first place, this fact is often overlooked in the “evidence base”, thus evidence around “poverty” is equally as important as evidence around “health inequality”

How this evidence is interpreted depends on whether a social or medical model of health is taken (arguably both are relevant); and the timeframe in which results are expected.

Marmot

Marmot 2013 remains the most valid and comprehensive guide

Reminder of key messages

• Gradient matters AS WELL as the most vulnerable. Proportionate universalism
• Injustice itself is a risk.
• Economic benefits of addressing – productivity loss, tax receipts, welfare payments, treatment costs
• Social factors; fairness and distribution of power; access to meaningful work; wages, taxation and cost of living; education, training and employment, housing, public transport and amenities; Social and community networks; Individual lifestyle factors; Healthcare
• The specific recommendations of marmot are NOT included in the table below, but noted in full further in this document

Marmot set out that reducing health inequalities will need action on 6 policy objectives:

1. Give every child the best start in life

• reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills.
• Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient.
• Build the resilience and well-being of young children across the social gradient.

2. Enable all children young people and adults to maximise their capabilities and have control over their lives

• Reduce the social gradient 1 in skills and qualifications.
• Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people.
• Improve the access and use of quality lifelong learning across the social gradient.

3. Create fair employment and good work for all

• Improve access to good jobs and reduce long-term unemployment across the social gradient.
• Make it easier for people who are disadvantaged in the labour market to obtain and keep work.
• Improve quality of jobs across the social gradient.

4. Ensure healthy standard of living for all

• Establish a minimum income for healthy living for people of all ages.
• Reduce the social gradient in the standard of living through progressive taxation and other fiscal policies.
• Reduce the cliff edges faced by people moving between benefits and work.

5. Create and develop healthy and sustainable places and communities

• Develop common policies to reduce the scale and impact of climate change and health inequalities.
• Improve community capital and reduce social isolation across the social gradient.

6. Strengthen the role and impact of ill health prevention

• Prioritise prevention and early detection of those conditions most strongly related to health inequalities.
• Increase availability of long-term and sustainable funding in ill health prevention across the social gradient.

The remainder of the blog sets out policy or intervention ideas led by multiple reviews of evidence over last 10 years.

References

Picket https://peg.primeeconomics.org/policybriefs/population-health-reduction-of-health-inequalities

Marmot – http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

Smith et al – https://www.ncbi.nlm.nih.gov/pubmed/25174045

British Academy. http://www.britac.ac.uk/publications/if-you-could-do-one-thing

Public Accounts Committee 2010. https://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubacc/…/470.pdf

NAO – https://www.nao.org.uk/report/tackling-inequalities-in-life-expectancy-in-areas-with-the-worst-health-and-deprivation/

McAuley A http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159256

Baum – https://croakey.org/beyond-the-social-determinants-a-manifesto-for-wellbeing/

Luchenski,- inclusion health, what works http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31959-1.pdf

NHS Scotland – Modelling the impact of policy interventions on income in Scotland –

Glasgow / Deep end

First published on the Sheffield DPH blog