Posts Tagged ‘Health inequality’

Local autonomy key to improving health outcomes

By Elliot Bidgood, research fellow at Civitas - 29th October 2013 12:48 pm

Engagement and accountability can be challenges in the NHS. This year, Mid Staffordshire and other hospital care scandals have brought both these issues and the general question of standards into particular focus.

In a new report for the think-tank Civitas, I have set out how the Swedish healthcare system may offer some sound lessons as we go about tackling these problems. The history and core ideals of their system are similar, in that they have a universal public system, developed in the post-war era and financed from general taxation. However, there are crucial differences in performance and structure, mostly relating to decentralisation and local autonomy.

Health outcomes in Sweden are better in terms of life expectancy, infant mortality and potential years of life lost (PYLL). According to a Lancet study this year, Sweden has the fewest preventable child deaths among 15 European nations, while Britain has the most. Sweden also performs better on mortality amenable to healthcare, the best available measure of deaths preventable by healthcare intervention. Sweden’s system is also rated highly in both international rankings and national surveys.

One compelling explanation for some of these differences is the placement of both day-to-day provision and broad taxation powers in the hands of county councils, which handle healthcare services, and municipal councils, which handle public health and social care. Over 70% of funding comes from local taxation. It is felt that this makes services flexible and more accountable to local electorates, strengthening engagement and creating pressure to ensure standards.

It may also explain their high turnouts in local elections, which allow Swedes to shape health services more than our general elections do, and the willingness of Swedes to pay more in tax and fund Sweden’s higher per-head health spending, since the value for money link is clearer.

Also comparable is the fact that Sweden has seen internal market and patient choice reforms, intended to improve efficiency and standards. However, these are more entrenched in Sweden, and have accelerated since 2006. Despite issues and a need for more evidence, Swedish patients have appreciated choice and it appears that in some areas, reform has improved accessibility, responsiveness, productivity and satisfaction.

Also crucial is the role that decentralisation has played in allowing localities to shape the reforms, innovate and learn best practice from each other.

A continual concern about decentralisation of course relates to the fear of “postcode lotteries”, hence why the Swedish state still provides extensive oversight and guidelines, as well as a quarter of all health funding, ensuring critical balance.

But we must also remember that centralism in the NHS has never truly stamped out variance and that democratic local control means that service differences are not a haphazard ‘lottery’, as they are shaped by local service users.

Future Forum boss joins NHS Commissioning Board

Pulse - 2nd September 2012 11:50 am

Former RCGP chair Professor Steve Field has been appointed deputy national medical director at the NHS Commissioning Board.

The appointment will mean Professor Field will have responsibility for reducing health inequalities in the NHS.

Professor Field is currently chairing a review of the NHS Constitution as part of his work on the government’s NHS Future Forum, which conducted the listening exercise on the Health and Social Care Bill last year.

Read more in Pulse.

Health inequalities: time to park the Health Bill

By Katherine Teale - 23rd January 2012 11:37 pm

Unless you’ve been hiding under the duvet for the last 18 months, you must be aware of the furore over the Health Bill, which has received a new battering this week from the Health Select Committee.

As a GP friend pointed out during a commissioning meeting, we work in an inner-city area where most residents take home less than the UK median wage (£23,000), and so, under the proposed system,  probably won’t be buying health insurance or ‘top ups‘, or whatever this will be called when the GP commissioners run out of money and decide that they can’t afford to fund procedure X or Y on the NHS. And that therefore if you require an X- or Y-plasty you will have to find alternative funding or just put up with it.

So poverty (or, at least, being unable to afford health insurance) and illness is going to be a bad combination - but if you’re a healthy doctor in the top 5% wage bracket and able to ‘work’ the health system, do you care?

Some do. NHSCA chair Dr Clive Peedell ran six back-to-back marathons this month to draw attention to the dismantling of universal healthcare - that’s what I call putting ‘skin in the game’.

Others, though, are less sympathetic, and take the view that the poor have only themselves to blame. Apparently they should have bothered to get themselves a good education when they were younger, and then they wouldn’t be in this mess. This was my second interesting discussion this week, and came on the back of complaints about our graduated car park charges, whereby a consultant on £90K has to pay about £15 a month more than a support worker on £18K.

“We don’t have to pay more for a pint of milk at Tesco just because we earn more.”  The Tesco argument is one which I’ve heard before, so this is not an isolated view.

I’m no saint when it comes to compassion - I don’t even  buy the Big Issue every week - but where do I start? For one thing, the comparison doesn’t work because, of course, poor people probably do pay less for a pint of milk at Tesco -  they simply avoid the organic or decent locally farmed stuff. Hospital car park charges are quite substantial (I pay over £30 monthly) and a significant burden for low paid workers taking home less than £1,000. Even means tested, it’s still a helluva lot more, proportionately, for them than for us.

My concern with this is that it’s a small step from saying it’s OK to price our poorly paid colleagues out of the car park, to saying that poor people don’t  deserve the same healthcare, because  they obviously didn’t try hard enough at school.

How appropriate that in the bicentenary of Dickens’ birth, we should be hearing about the undeserving poor. Doctors have traditionally stood up for the poor and the sick. As well as getting angry about the theft of our pension funds, we should all be striving to preserve the NHS as a good, universal service for all - even for those who didn’t manage 10 GCSE’s. Please sent an email to your Royal College president asking them to support dropping the Health and Social Care Bill.

Doctors should be ‘community leaders’ as well

by Mike Broad - 18th October 2011 8:50 am

Doctors have a key role to play in reducing health inequalities, says a new report.

Social determinants and health inequalities pose a significant challenge to governments around the world and the BMA’s report highlights how doctors can use their expertise to act as community leaders to tackle this issue.

Dr Vivienne Nathanson, director of professional activities at the BMA and author of Social determinants – what doctors can do, explains that the social determinants of health are factors that impact on health and wellbeing for which there is little control, for example, where we are born, grow up, live, work and our gender and age.

While these factors are not usually directly responsible for ill-health they have been described as ‘the causes of the causes of disease’. For example, while smoking may lead to heart disease and lung cancer, it is the social factors that largely determine whether an individual is more or less likely to smoke, and if they start to smoke whether they are likely to quit successfully.

The report emphasises that while not every doctor has the opportunity to change the life course of individual patients they can make a difference in others ways to reduce health inequalities on a local, regional, national and international level.

Dr Nathanson highlights examples of work doctors and their teams are already involved in, these include the Bromley-by-Centre in East London where GPs refer patients to professionals from welfare, employment, housing and debt advice services so that the underlying causes of their health problems can be addressed.

Other examples include doctors working with homeless people in Glasgow and clinicians at the Royal United Hospital in Bath developing training programmes to help staff improve the care they provide to profoundly deaf patients.

Dr Nathanson said: “We have some very good examples in the report but we will be seeking more so that we can develop a resource to help doctors exchange ideas and best practice in this area.”

She added: “Having Sir Michael Marmot, the global expert on health inequalities and author of Fair Society, Healthy Lives as our recent president provided the BMA with an ideal opportunity to develop our work on social determinants and health inequalities.

“We are committed to continuing with this project and will press the four UK governments to assess the health impact of all policies and interventions with a special emphasis on the social determinants of health. We will also urge the General Medical Council and the medical royal colleges to include an understanding of social determinants in examinations syllabi for future doctors.”

Read the full report.

Trying to close the gap in times of austerity

By Dr Vivienne Nathanson, BMA director of professional activities - 22nd February 2011 4:39 pm

At a conference on health inequalities held at the BMA recently, a member of the audience asked if it is possible to reduce the health inequalities gap during times of financial constraint.

Sir Michael Marmot, the global expert on health inequalities and BMA president, gave an inspiring keynote speech. He talked about the social gradient in health and well being from the poorest to the richest and explained that while the overall health of the nation had improved in the last decade, the gap between the haves and the have-nots has widened.

One speaker made the point that if you stand on top of leafy Primrose Hill in London and look down towards the more urban Somers Town, an area near Kings Cross, the decrease in life expectancy is about nine years.

Despite the gradient, it is still the poorest in society who are most likely to suffer from complex illnesses related to obesity, mental illness, alcohol misuse and tobacco addiction and these significantly contribute to health inequalities. The tragedy is that so many of these illnesses are avoidable.

At the end of the conference the question about funding came up - with the NHS looking to make around £20 billion in efficiency savings and go through massive structural change - are innovative projects dealing with health inequalities going to be priority?

Sir Michael Marmot answered that “doing nothing costs money”. If doctors can work in partnership with other healthcare professionals and help reduce teen pregnancies, provide guidance about parenting skills and promote healthy eating and exercise in children and adults it will be NHS and society who will reap the benefits in future years.

These initiatives will help people live longer healthier lives and will save the healthcare billions of pounds.

A greater threat perhaps than funding are the implications of the Health and Social Care Bill and the proposals in the white paper on public health.

While it is positive that health inequalities are central in the white paper, there is a real risk that the current decimation of PCTs could mean that the expertise and skills of dedicated staff who know how to run projects to tackle health inequalities will be lost.

The government’s proposals of enforced competition between healthcare providers where price is a key factor will also be barrier to reducing health inequalities. It is unlikely that the private sector will want a slice of this particular pie as the services aimed at the vulnerable and poor will not be cheap or profitable.

The news wasn’t all bleak however. Sir Michael Marmot made the point that the UK has the most equitable health service among the richest countries in the world. This is something we should be really proud of and do everything we can to protect - without it, it is likely that the gap in health inequalities will widen even further.

Age, sex and wealth affect referral to secondary care

BBC Health - 1st December 2010 11:08 am

Age, sex and wealth all affect how likely your GP is to refer you for a specialist appointment, a study has concluded.

A UK team analysed data for 130,000 patients, reporting their findings in the BMJ.

Older people were less likely to be referred for three common symptoms, with sex and deprivation also influential.

A charity said the study should raise alarm bells across the NHS.

Michelle Mitchell, Charity Director at Age UK, said: “A doctor’s decision to refer patients must be based solely on the patient’s clinical need, not their age. Age discrimination in health provision will be unlawful from 2012 and it can’t come a moment too soon for older people in need of medical care.”

The study from the King’s Fund and University College London covered decisions on patients with postmenopausal bleeding, hip pain and heartburn from 326 UK practices across a six-year period.

Read a blog on the issue.

Read more at BBC Health.

Labour Party savaged over health inequalities

The Lancet - 16th November 2010 11:02 am

The Lancet remembers well the genuine excitement we felt at the commitment that the Labour government made in 1997 to attack health inequalities in Britain.

The dismal record of the Conservatives before them left a deep scar on the NHS. The creation of Donald Acheson’s Independent Inquiry into Inequalities in Health was a new opportunity to recalibrate the health service to meet the needs of the most deprived communities in the UK. Our sense of hope was, it turned out, misplaced - Labour presided over 13 years of failure.

Inequalities in health widened despite huge investment in the NHS. The reasons for this failure have now been exposed in an astonishingly candid report, published by the House of Commons Public Accounts Committee. This committee examines how taxpayers’ money is spent. It is chaired by a Labour Member of Parliament, Margaret Hodge. She has produced a tale of decrepitude at every level of the health system.

Labour was elected in 1997 with a promise and mandate to tackle inequalities in health. Yet it took nine years (to 2006) before ministers and their civil servant officials made inequalities an NHS priority.

“What on earth went wrong?” asked Hodge. She was questioning the Department of Health’s Permanent Secretary, Richard Douglas, together with Ruth Hussey (a regional director of public health) and Mark Davies (the Department’s Director of Health Inequalities).

Douglas was evasive. Hodge dismissed his “claptrap” as “despairing”. Eventually, he admitted that his Department’s interpretation of ministers’ election commitments was merely “aspirational” (ie, it did not have to be taken seriously).

The picture of government he painted was far from flattering. Figures showing the worsening situation for health equality would be sent to the Department and forwarded to ministers. But civil servants - including, it seems, the Chief Medical Officer - did little to address the growing problem. The best officials could do collectively was send out “toolkits” of guidance to PCTs and cross their fingers that they might trigger a response.

But the Department had no mechanism to monitor or evaluate the implementation of what limited guidance it did provide. It was a “fair criticism” to say that “we were slow off the mark”, conceded Douglas. Members of the Public Accounts Committee were clearly shocked by this admission.

The government and civil service were not wholly to blame. Where was the medical profession? Doctors are supposed to feel an acute responsibility to deliver the best health service to the whole population. It is on this basis that they ask the public and government to support generous pay increases and terms and conditions of service. These attitudes and behaviours are what we commonly mean by professionalism. It seems that doctors failed completely to live up to the rhetoric of their commitment to professional values.

Members of Hodge’s committee tried to find out why doctors had been so reluctant to address inequalities themselves.

There are some simple and proven interventions that, if implemented evenly across the population, would go a long way to reduce inequalities in health - notably, smoking cessation and the treatment of high blood pressure and raised cholesterol. But doctors did not respond to the clear public and political call to take action on inequalities (and nor did the media). Instead, they sought to massively increase their salaries in a new general practitioner (GP) contract in 2005, one that itself was empty of commitment to reduce inequalities.

People died because of this professional failure. The negotiators of that GP contract, together with the Department of Health, share a responsibility for those deaths.

During the course of this systemic failure, the Department of Health employed over 2300 people. Mr Douglas earns £170,000. Yet this great number of civil servants and their highly paid Permanent Secretary failed to deliver on a public promise, democratically endorsed. A bureaucracy’s first priority is usually to protect itself. Only secondarily will it try to deliver on the pledges of its political leaders.

To call this period in the Department’s history shameful does not even begin to do justice to the way it let down the millions of people to whom it owed a duty to serve.

Despite the bland reassurances made to the Public Accounts Committee, there is not one shred of evidence that the Department has learned the lessons of this agonising debacle.

This article first appeared as an editorial in The Lancet.

Government failed to tackle health inequalities

By Mike Broad - 15th November 2010 11:53 am

The Department of Health has failed to tackle health inequalities in England, a parliamentary report claims.

A cross-party group of MPs that examines public spending criticised the DoH for being too slow to develop an evidence base of cost-effective interventions to reduce inequalities, and for failing to adequately to address GP shortages in areas of highest need - missing an opportunity with the GP contract.

Furthermore, the House of Commons Committee of Public Accounts urges the new government to ensure GP consortia are made more accountable for measures to cut inequality.

The committee looked into why the health department has failed to reach the target set by the government in 2007 of reducing the gap in life expectancy by 10% between councils with high deprivation and the population as a whole by 2010.

Although life expectancy in the whole population has risen, the gap between the national average and the deprived areas has widened by 7% for men and 14% for women since 1995-7. Life expectancy in the whole population is now 77.9 years for men and 82 years for women, whereas in the 70 deprived councils it is now 75.8 years for men and 80.4 years for women.

Only 12 of them are on track to shrink the gap in life expectancy of men and women.

The report also reveals that two thirds of PCTs in areas with the highest deprivation still do not receive the money due to them under the DoH’s funding formula.

Margaret Hodge, the committee’s chairwoman, said: “A central challenge for all governments is to reduce health inequalities between the affluent and the disadvantaged. The problem is complex, but the fact that the gap continues to widen is of great concern, especially against a background of a general improvement in public health over the last decade.”

The report concludes that addressing health inequalities requires sustained and targeted action.

“The Department’s experience to date shows that greater focus and persistence will be needed to drive the right interventions. We expect the Department to provide strong leadership and to continue to monitor the outcomes of those suffering health inequalities. As there is an inevitable time lag between public health interventions and observable outcomes, the Department should monitor the implementation of those activities which, in the short term, would be strong indicators of progress,” it says.

Read the report’s recommendations.

Read a blog on the issue.

Doctors urged to tackle health inequalities

By Mike Broad - 11th June 2010 1:16 pm

Doctors must strive to reduce health inequalities among patients, a new report urges.

The report, called How doctors can close the gap: tackling the social determinants of health through culture change, advocacy and education, suggests that disadvantage results in vast gaps in health and mortality, but these inequalities are not inevitable.

It identifies how doctors can take account of social inequalities in every area of their work, calling for changes to medical practice and consultations and encouraging doctors to use their influence to promote health equality.

The refocusing of attitudes and resources in healthcare towards prevention rather than treatment of illness, is a key recommendation.

Doctors are also urged to ensure they identify opportunities to help patients from disadvantaged backgrounds to manage their health, taking into account their social and physical environment and to encourage patients from marginalised groups to access health information, screening and health promotion services.

The Royal College of Physicians, Royal College of General Practitioners, Royal College of Psychiatrists, Faculty of Public Health, National Heart Forum, and the NHS Sustainable Development Unit collaborated to produce the report.

Prof Ian Gilmore, president of the Royal College of Physicians, said: “At present, many doctors and other health professionals do their best to treat the patient in front of them, but they do not always look beyond the symptoms presented, and address the patients’ social and economic background.

“This becomes a vicious cycle, where people are treated for an illness, go back into the community and fall ill again, because doctors have not been able to address the reason they were unwell in the first place.”

Other recommendations include: encouraging patients to undertake healthy activities; urging doctors to join forces to advocate health equality at all levels, from impassioned medical students to influential deans and directors; restructuring the undergraduate and postgraduate education of doctors to make the public health and social aspects of the courses more engaging; and, more information-sharing between doctors, public health teams and researchers on best practice in reducing inequalities.

Prof Alan Maryon-Davis, president of the Faculty of Public Health, said: “Doing what we can to remove some of the unfair barriers to better health and well-being is not just the province of public health specialists. All doctors can help to reduce the ‘health divide’ in various ways. I hope this report will stimulate not just reflection and discussion, but also action.”

Read the full report.

Marmot Review: Reducing health inequalities in England

By Mike Broad - 20th February 2010 11:06 am

In November 2008, Professor Sir Michael Marmot was asked by the health secretary to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010.

The strategy will include policies and interventions that address the social determinants of health inequalities.

The Fair Society, Healthy Lives review had four tasks, including the identification of relevant evidence; demonstrating how this evidence could be translated into practice; advising on possible objectives and measures, building on the experience of the current PSA target on infant mortality and life expectancy; and, the publication of a report of the review’s work that will contribute to the development of a post-2010 health inequalities strategy.

A summary of the key messages:  

1. Reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life.

2. There is a social gradient in health - the lower a person’s social position, the worse his or her health. Action should focus on reducing the gradient in health.

3. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health.

4. Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is called proportionate universalism.

5. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs.

6. Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals.

7. Tackling social inequalities in health and tackling climate change must go together.

8. Reducing health inequalities will require action on six policy objectives: give every child the best start in life; enable all children young people and adults to maximise their capabilities and have control over their lives; create fair employment and good work for all; ensure healthy standard of living for all; create and develop healthy and sustainable places and communities; strengthen the role and impact of ill health prevention.

9. Delivering these policy objectives will require action by central and local government, the NHS, the third and private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies. Effective local delivery requires effective participatory decision-making at local level. This can only happen by empowering individuals and local communities.

Marmot Review conclusions

Social justice is a matter of life and death. It affects the way people live, their consequent chances of illness and their risk of premature death.

This is the opinion of the Commission on Social Determinants of Health set up by the World Health Organisation. Theirs was a global remit and we can all easily recognise the health inequalities experienced by people living in poor countries, people for whom absolute poverty is a daily reality.

It is harder for many people to accept that serious health inequalities exist here in England. We have a highly valued NHS and the overall health of the population in this country has improved greatly over the past 50 years.

Yet in the wealthiest part of London, in one ward in Kensington and Chelsea, a man can expect to live to 88 years, while a few kilometres away in Tottenham Green, one of the capital’s poorer wards, male life expectancy is 71.

Dramatic health inequalities are still a dominant feature of health in England across all regions. But health inequalities are not inevitable and can be significantly reduced.

They stem from avoidable inequalities in society: of income, education, employment and neighbourhood circumstances.

Inequalities present before birth set the scene for poorer health and other outcomes accumulating throughout the life course.

The central tenet of this review is that avoidable health inequalities are unfair and putting them right is a matter of social justice. There will be those who say that our recommendations cannot be afforded, particularly in the current economic climate.

We say that it is inaction that cannot be afforded, for the human and economic costs are too high. The health and well-being of today’s children depend on us having the courage and imagination to rise to the challenge of doing things differently, to put sustainability and well-being before economic growth and bring about a more equal and fair society.

Reaction to the review

Professor Mike Kelly, director of the Public Health Excellence Centre at NICE, said: “Public health interventions are extremely good value when compared with the costs of clinical interventions. We need to shift the emphasis away from medical interventions that treat existing illnesses to interventions to prevent those illnesses developing in the first place, but it needs political support and system change to make this happen.

“A modest switch in resources to public health, to invest in those interventions which have been shown to be effective and cost effective by NICE, would from a societal point of view and a social justice point of view, be an important investment for the future.”

The King’s Fund acting chief executive Dr Anna Dixon said: “The problems that contribute to health inequalities are complex and longstanding. It is clearly the role of the NHS to help everyone improve their chances of living longer and healthier lives. But the health service cannot eradicate these inequalities on its own.

“The onus is on government to address health inequalities as a cross-departmental issue and to support not just NHS efforts but programmes that address the wider determinants of health - like housing, working conditions and early childhood education.

“The political obstacle is that cash invested in initiatives to tackle health inequalities doesn’t produce instant returns. It’s imperative that politicians continue to support the reduction of inequalities as a goal, even if the outcomes might not be achieved until after they have left office.”

Read the full review.