NHS England say “We have failed to tackle health inequalities and must do so much more!”
Here is a quote from a “scene setter” report on health inequalities which went to the March 2018 Board of NHS England.
“We have made positive progress in fulfilling our legal duties to reduce health inequalities and have made health inequalities a priority in implementing the NHS five year forward view”
Yet this table from the same report presents a different picture – positive progress?
Sometimes the language of bureaucracies dispirits me. We often get bland statements – that basically say – “no cause for worry we have fulfilled our legal duties” when we actually need a rallying cry…..
“we have failed to tackle health inequalities and we need to do so much more!”
This paper is a good illustration of why we lack this rallying cry.
Context
There are two significant omissions to this report. There is no definition of what is meant by health inequalities – and following on from this there is no mention of the context within which health inequalities currently exists in the UK.
We have to come clean and say that health inequalities is avoidable disadvantage experienced as a result of peoples socio-economic status. Of course there are other disadvantages that people can experience as a result of their disability, race, gender, age etc but these equality issues are not synonymous with inequality.
A note on context – we are in the middle of a period of severe cuts to local government and other services that are intended to tackle inequality – see here (Guardian – local govt cuts), here (JRF report) and here (Guardian – benefit cuts).
This scene setting paper mentions none of these issues – yet it promotes integrated care systems!
Lack of a coherent narrative.
As Mike Chitty (quoting George Monbiot) said in a recent tweet
This paper has lots of facts – its starts using an ONS classification that I was not familiar with. This breaks local authority areas down into a set of categories – supergroups – for example “services and industrial legacy” and “Business and Education Heritage Centres” etc. Later the report compares “most deprived areas”to least deprived – I think by population groups of 100,000 population.
I know this issue is complex but I come away confused and unclear about the scale of the population affected and lack an insight into what this means at a population level.
The different approaches are confusing and risk repeating the mistakes made by the Labour Government Spearhead Programme. It focussed on local authority areas which have a high proportion of people who experienced health inequalities (a bit like the services and industrial legacy group), however cities like Sheffield were not recognised because the proportion of people who experienced health inequalities was smaller, even though the actual number of people who experienced health inequalities was larger!
People or Conditions?
Further in the report health inequalities is described according to condition – Cancer, mental health etc.
This exemplifies the siloed approach of the NHS commissioning model. It appears as though though we are talking about different populations with regard to health inequalities – when of course we are not. This is particularly the case if we take into account the burden of disease that people who experience health inequalities carry at an earlier stage in their lives – see this blog from Peter Hoskins editor at Conservative Home!
We need something that brings all this together. Maybe a narrative path that goes something like this:
Low income and financial insecurity ➪ poor mental health and wellbeing ➪ poor physical health
Lack of systematic actions
It feels as though NHS England is scraping the barrel here while there are a range of initiatives mentioned it acknowledges that many of these are pilots, it mentions the Improving Access for All toolkit which I critiqued here, and Social Prescribing. Its hard to see why other initiatives such as Personal Budgets (with just 23k people on them!) are included – is NHS England saying that this is a programme specifically addressing health inequalities?
It does talk about the need to review the financial allocations formula – which is positive – however I suspect that this will take a rather long time and without a decent analysis of inequalities (see above) is unlikely to deliver.
What next?
NHS England need to work with the Local Government Assocation and key organisations such as the Institute of Health Equity, Joseph Rowntree, Citizens Advice, the Money and Mental Health Policy Institute and the Royal College of Psychiatrists to produce a coherent narrative that sets out the health inequality challenge – everything else follows from that.
What do you think?
A great read Mark! Once again you hit the nail on the head. I am always wary of self congratulatory statements that either contradict the evidence or lack any to support them, they are not reassuring.
I’m also concerned about the main streaming of services for minority groups who need a specific ‘Offer’ to address the health inequalities they face, especially when the process of main streaming itself is used to justify addressing the issue of inequality! Providing everyone with equal access to the same service takes no account of their willingness or ability to use it. Removing some barriers while creating others in the process isn’t helpful.
It seems that no one really wants to grasp the nettle of the socio economic factors at the heart of health inequalities, it’s complicated, messy and political.
Thanks for the comment NB – if I understand you correctly – I agree that one of the real tensions is how to provide services that are relevant to the needs of specific communities whether these are communities of interest or geographic. I think that nationally prescribed funding regimes and contracts can often impose solutions – for example additional funding that can only be spent on GPs when what might be needed is better access to physiotherapy or social prescribing or welfare rights.
Thanks for that Mark. There is a lack of flexibility in the process which can impact of creative, imaginative solutions. To be fair to those commissioning and procuring services, time constraints, competing priorities and what seems like significant ‘churn’ doesn’t help. You have previously highlighted the importance of access to welfare rights services and I wholeheartedly concur. I am persuaded of the merits of social prescribing but very concerned about the lack of funding. Many people think it is a great idea but no one wants to pay to make it happen which is a shame because potentially it is a great way to address health inequalities and provide people with services they want and will use. I very much appreciate your insightful considered approach to these issues and learn something from your posts, you are a great resource keep up the good work.
Full disclosure – that recent tweet from me was quoting George Monbiot from Out of the Wreckage! Great blog. Seems like there are some interesting things happening in Sheffield?
Cheers Mike – I will tinker with the blog so that the attribution is clear! Yes interesting times – plenty of things to have a go at and as with everywhere else some good people to collaborate with.