Tackling inequalities through the NHS


Evidence to the Health Select Committee

The Socialist Health Association was founded in 1930 to campaign for a National Health Service and is affiliated to the Labour Party. We are a membership organisation with members who work in and use the NHS. We include doctors and dentists and other clinicians, managers, board members and patients.

Our members are involved in a wide variety of consultation and involvement processes in health and social care. We have been particularly concerned about health inequalities for many years and many of our members are involved in work to reduce inequalities and in study of relevant areas. This submission is made on behalf of the Association. We would be very happy to give oral evidence to the committee.

The increase in the relative disadvantage of the poor has been continuing for a long time. Richard Titmuss, writing during the Second World War, concluded that, “the inescapable lesson of this study is that the infants of the poor are relatively worse off today than they were before the 1914 war.” (Titmuss, 1943). The Black Report concluded, “Perhaps the most important general finding […] is the lack of improvement, and indeed in some respects deterioration, of the health experience not merely of occupational class V but also class IV in health, relative to occupational class I… during the 1960’s and early 1970s.” (DHSS, 1980). Sir Donald Acheson found, “that although the last 20 years have brought a marked increase in prosperity and substantial reductions in mortality to the people of this country as a whole, the gap in health between those at the top and bottom of the social scale has widened” (Acheson, 1998). This trend has persisted regardless of efforts, or lack of them, by governments of different persuasions, including the present one, for half a century or more (Scientific Reference Group on Health Inequalities, 2005).

Recent OECD figures show that Inequalities in wealth, which mirror inequalities in health, are greater in the UK than in most other developed countries and show no signs of reducing. In the period, 2003-06, the UK wealth 20:20 ratio was 7.2 with only Portugal and the US having higher ratios among the richest countries. The lowest ratio among these countries was 3.4, found in Japan. It seems very clear from the work of Sir Michael Marmot and Prof Richard Wilkinson that the increasing inequalities of wealth in our society – which grow wider during periods of economic growth – are the main drivers of inequality in health and that measures taken by the NHS will never be more than palliative.

Brian Abel-Smith argued: “if socialists believed forty years ago that all that was needed to equalise health status between social classes was to remove the money barriers to access to health care, they were seriously mistaken” (Abel-Smith, 1984). The scope for the NHS to contribute significantly to the reduction in health inequalities is very limited as demonstrated in the Acheson Report but this is no excuse for not using this scope to the maximum.

One of the underlying causes of the inverse care law must be that healthcare has been almost entirely demand led. Doctors wait for patients to come to them. It is not surprising that the most demanding patients demand and get a better service. Without affirmative action to identify the healthcare-deprived in order to provide appropriate high quality healthcare the NHS will continue to increase health inequalities because the health-advantaged currently get more out of it than the health-disadvantaged. Introducing more screening for those not currently exhibiting symptoms is likely to further exacerbate inequalities unless active steps are taken to to counter this.

Affirmative action needs to take place at three levels – the Area level, the individual General Practice level and the focused Group level.

Some Areas can readily be identified as comprising high numbers of healthcare-deprived people and here an Area-wide approach with increased provision of easily accessible relevant healthcare services such as health visitors, outreach outpatient and diagnostic services and branch surgeries is required. Recent advances in the use of information technology make some of these approaches much more practical. There are now a number of tools that analyse population patterns at postcode area levels. These approaches began in the commercial fields, it’s how supermarkets decide where their customers are and where to mount marketing activities but the same methods can be used to identify particular deprived groups who have specific health care needs.

One example is Experian’s Mosaic classification; by linking this sort of social data with health data a targeted approach at the community level is possible.

For example:

Group F 37 – [Low income younger families with children in small, hard to let blocks of public sector purpose built flats] are 3.8 times more likely to have teenage pregnancies

Group I 50 – [Old people in specially constructed accommodation mostly managed by local authorities, many with a resident warden] are 6.3 times more likely to have a preventable winter admission

Group D 25 – [Young, unattached people in small flats and older housing close to small town centres] are 3.3 times more likely to have an emergency mental health admission.

(Source Dr Foster Intelligence. See also the work of Dr Sohail Bhatti, recently DPH for Huddersfield)

This is outreach at the area level.

At individual GP level it should be possible to identify healthcare- deprived patients from the Practice List and then make contact with them to ensure that they take full advantage of all the relevant services they need. This should be supported and motivated by the creation of a QOF specifically related to the inequalities issue for which the EPIC-Norfolk Prospective Population Study provides an evidence base. Four simply defined behaviours—smoking, physical activity, alcohol drinking, and fruit and vegetable intake are shown to have an enormous influence on life expectancy, and it must be possible for these to be recorded and improved at practice level. .This is outreach at the individual patient/family level

There are also health-deprived people who are not on Practice Lists for various reasons, for example the homeless. For these people a focused group outreach approach is required with staff actively seeking out such people and taking whatever steps are necessary to ensure they get the healthcare they require.

Bearing in mind the importance of the wider determinants in health another important role for the NHS is for someone at GP Practice / Health Centre / Polyclinic level to develop what we term the neighbourhood / community public health role in order to initiate and coordinate local action to ensure that the wider determinants environment is optimised for the local population including the health/healthcare deprived population.

There are in our view three key platforms for delivering community health and wellbeing focused particularly on the health deprived namely:

  • general practice
  • community schools/colleges working in a coordinated way
  • community development

Our proposed model envisages Practice premises or where they exist, Health Centres/ Polyclinics, providing a range of services, in addition to the traditional primary healthcare services, such as Benefits Advice and social services; and acting as a signpost to relevant services such as housing advice and environmental health. At the same time, by working with local community development workers, health protective social networks could be formed.

The local secondary school acting as a community school or college would provide education and lifelong learning opportunities as well as sports facilities and opportunities for social activities of various sorts. Public health leadership would be provided from the platform of the local GP Practice or Health Centre/Polyclinic either by a suitably trained General Practitioner, or more likely, by a health visitor or health promoter working within the primary care team and relating to the local community and its key institutions, often through community development. This approach to developing community public health harks back to the revolutionary model adopted in the Peckham Pioneer Health Centre in the 1930s.

In addition we propose that:

1. All new NHS policies, programmes and projects should be subject to both a healthcare accessibility inequalities assessment and a healthcare quality inequalities assessment.

2. Similarly, all NHS public health policies, programmes and projects should be subject to a broadly based health and wellbeing inequalities impact assessment.

3. As recommended by the Acheson Report, all government domestic policies, programmes and projects should be subjected to such an assessment as all have some impact on health and on health inequalities.

4. Responsibility for tackling inequalities at national level must be allocated to a senior civil servant and a senior politician of cabinet rank; similarly, responsibility at local level must be allocated to a senior official and a cabinet rank councillor within local government; and to equivalent officers and members in Primary Care Trusts and NHS Trusts. It is crucial that these named officers, politicians and members have cross-departmental/divisional responsibilities and powers

5. It must be a mandatory duty on the national government and on local authorities and NHS primary care and hospital Trusts to produce an annual account of their actions and the results of these actions to reduce inequalities.

6. The designation of the reduction in inequalities as a key performance indicator for the NHS and Public Health must be matched by a clear line of accountability at all levels for delivery.

7. The resource allocation formulae used to distribute funds to local authorities and Primary Care Trusts should, as specifically recommended in the Acheson Report, give more weight to measures of health and material deprivation.

8.Inequalities issues almost invariably require cross-cutting action involving primary care, secondary care and public health elements of the NHS as well as one or more arms of local government and in many cases voluntary and community organisations too. Coordination and energisation of such action, often by means of LAA’s and JNAS’s, through local collaborative partnership working is crucial to success.

Below are two specific contributions from SHA members which we fully support.

Health Inequalities and why we fail to change them

Prof Rod Griffiths

Inequalities in health outcomes have been with us a long time. The geographical pattern of lower life expectancies in some areas associated with poverty has been roughly similar across the country for the lifetime of everyone living in the UK. There have been some variations as the population has grown and the built area has expanded but the basic pattern has persisted. One major reason for this is the planning acts which have now been in place in one form or another for a lifetime. These acts work to keep the country looking like it always has, in other words it keeps poor people in poor places, maintains differentials in property prices and housing density, keeps industry in the same places, determines transport patterns and so on. The effect is to preserve geographical inequities.

As an example, when I was first a DPH in the 1980s and 90s it used to be the case in Birmingham that the almost only way you could get to live in Nechells was to not pay the rent somewhere else, the housing department would then move you to Nechells. There were other sink estates but at the time that I first became DPH in Central Birmingham about 85% of the people in Nechells were on some sort of benefit. Those who did get a job moved out as fast as they could and were replaced by someone else who was down on their luck. Nothing that the health authority did was likely to alter the pattern of health inequality because the benefit, planning and housing systems made sure that things stayed the way that they were. To large extent these policies followed social expectation and electoral pressures. Things stayed the way they were because the majority of the population expected them to be that way.

Some things did change. In the 60s the housing in Nechells was transformed, the old slums were demolished and replaced by tower blocks, but the pattern of income distribution stayed the same. Old factories were demolished and replaced by modern facilities. As a result, although unemployment was high, what work there was, was safer. Pro rata industrial accidents and sickness at work were lower in Nechells than in some parts of Birmingham where the buildings were not demolished.

Across the UK similar patterns persist. If we measure health inequalities on a geographical basis then rapid change is very unlikely.

The second lesson from history is that although the pattern has remained fairly constant the actual causes of death have changed. A hundred years ago the poor died from infectious diseases made more likely by overcrowding and poor sanitation. Later respiratory disease caused by air pollution became more prevalent and now the poor die from smoking and obesity, which used to be afflictions of the rich.

Obviously the medical model is effective in seeking cures for the individual diseases but it does not work to tackle inequalities. As one disease is cured it is replaced by another and the social processes of our society work to ensure that the poor will die sooner than the rich. HIV is the latest disease to change its pattern in this way. We first saw it as a disease of well off and hedonistic homosexuals but across the world it has rapidly become a scourge of the poor and black, while death rates in the rich, whatever their sexual orientation, have fallen rapidly.

Across the world we see similar patterns but the relative steepness of the gradient between rich and poor varies considerably in different countries. It is a sad fact that the UK has some of the greatest health inequalities. The figure below, taken from the UN Commission on Social Determinants of Health gives some idea why this is. Most of Europe is more generous in its support to families than the UK or USA and as a result has better health inequalities and in most cases longer life expectancy.

The UN commission concludes that “The devastating health inequities we see globally are man-made. The causes are social – so must be the solutions. A global society in which millions of children and adults are unable to lead flourishing lives is not sustainable.”

Do Hospitals make a difference?

Treating diseases is obviously a good thing. Few studies have looked at what happens inside hospitals, many years ago I analysed the outcomes of treatment from heart attacks looking at the case fatality rate for different income and poverty groups. I selected heart attacks as being something where there were less likely to be social barriers to immediate admission. There was very little difference in outcome between rich and poor. Once a patient is admitted to hospital the NHS pays very little attention to issues like income, housing tenure, car ownership, education or any other markers of income and social status but there is a big difference between rich and poor when we look at outcomes at a population level. The damage is done outside hospital. Some of the problem may be in primary care, GP list sizes are often bigger in poorer areas and the quality of care is often less good. There are of course heroic examples of GPs in poor areas who have done exceptional work over many years. Some, like Julian Tudor Hart have published their methods and results but their work has not been taken up universally and the lessons have not been translated into government policy or driven into practice by the NHS.

There are deep attitudes in British society that accept and reinforce social determinants of health. I once suggested that everyone from poorer areas should be given a three month start on the waiting list on the grounds that poorer access and education would have delayed their presentation with whatever condition that they had. I tried the suggestion on a number of audiences, both lay and professional and was always told that it wouldn’t be fair, despite the fact that the current outcomes are manifestly not fair. As one GP said to me some years ago “If I’ve got two patients who need a CAGB and one runs Rover and the other is a down and out, I can’t send the down and out in ahead of the chap from Rover, can I – think about all those jobs that depend on him.” As long as we tend to think like that health inequalities will continue.

Has the NHS made it worse?

Over the last decade, on average, admissions to hospital in better off areas are more likely to come via waiting lists and in poorer areas by emergency. Roughly speaking 60% of admissions are via waiting list in rich areas and 40% in poor areas. Giving priority to waiting lists targets money towards the rich.

Targeting waiting lists also presents a very different management challenge in different parts of the country. If we look at the ratio between emergency admission and elective admissions it varies by a fact or three across the current PCT (Source – publicly available HAS data). It seems probable that this variation is part of the root cause of the pattern of deficits that built up over the decade. A number of studies suggested different reasons for this pattern; obviously poor management must be part of it but it was noticeable that outside London deficits tended to be higher in areas that were better off and less in inner city areas. At the same time as driving the waiting list policy the government also tried to put more money into public health and had an allocation formula that gave more to deprived areas. The three policies simply do not fit together. In the end it was the waiting list policy that came out on top and both public health funds and general budgets in solvent PCTs were raided to pay off the deficits in the other areas. Placating middle class demands for health care was given greater priority than preventing illness and reducing inequalities. For the last decade this has been government policy, there has been considerable success in reducing waiting lists but it is hardly surprising that health inequalities have got worse.

Prof. Rod Griffiths CBE

About the Author

  • In the early 1970s secretary of the Socialist Medical Association ( now the SHA)
  • 1974 – 1981 CHC member Central Birmingham
  • 1979 -81 Chair of the Association of CHC for England and Wales
  • 1982 – 90 Director of Public Health Central Birmingham
  • 1990 – Professor of Public Health University of Birmingham
  • 1993 – 2004 Regional Director of Public Health West Midlands
  • 2004 – 2007 President of the Faculty of Public Health
  • Currently chair National Commissioning Group

Oral health inequalities

Dr John Beale

Whilst oral health has improved in the UK over the past couple of decades unacceptable inequalities remain, with those from the most deprived sections of the community and from some minority ethnic groups having the highest levels of dental disease. These groups are also the least likely to be regular attenders at the dentist. Not only is oral health an integral part of general health but there is also evidence that poor dental health is associated with some other diseases. For example, there are several studies that have demonstrated an association between periodontal disease (poor gum health) and an increase in heart disease, even after other confounding variables such as age, gender and social class are taken into account. Conversely, one of the common complications of diabetes is poor gum health. The most important factor in causing oral cancer is smoking, and this is linked to socio-economic status.

It is therefore important that inequalities in dental health are addressed in any strategy for improving the health of the community. This needs to be considered both with regard to the prevention of poor oral health and also encouraging those with the poorest oral health to seek regular dental care.

Although, no doubt worthy, much health education serves to widen inequalities as it relies on action being taken by the most deprived and excluded groups and often involves adopting more expensive lifestyles such as low sugar, low fat diets. The most cost-effective method of reducing the prevalence of tooth decay is through water fluoridation. All social groups benefit but the most socially deprived sections of the community benefit most and inequalities are reduced. This was addressed in the Association’s evidence on primary dental care and it is re-iterated that Ministers should ensure that all PCTs and SHAs review the need for fluoridation without delay.

Numerous studies have shown that dental charges are a barrier to seeking regular dental care. The new contract, in which patient charges for fillings are the same no matter how many fillings are required, may have the perverse incentive of encouraging less well off patients to delay going to the dentist until a number of fillings are needed rather than attending regularly and having one or two fillings in each course of treatment. Many ‘white collar’ workers are salaried and do not lose financially when they visit the dentist. Those on low wages, however, often lose money if they have time off from work. PCTs should ensure that dental services are available at times which are convenient to patients.

Whilst oral cancer can occur in all adult age groups, it is predominantly a disease found in older people, especially heavy smokers. The prognosis is much better when the disease is diagnosed early. Older people are inclined to attend a dentist less often, especially if the have full dentures (itself associated with social status). Removing the financial barrier to seeking regular check-ups would help to encourage more frequent attendance in the groups most likely to have oral cancer and hence facilitate earlier diagnosis. Consideration should be given to providing free dental examination for those aged over 60 years, as it is in Scotland. This age group already have free prescriptions and eye checks and it is difficult to see why dental checks shroud be different.