Making progress on tackling health inequalities is not just about getting the right evidence – it means challenging power, shifting culture and changing how we work. In order to do this we need a clear narrative – a story – that empowers champions, motivates the undecided and challenges the unconvinced.
We have struggled to do this – for example a decade ago it was a real success when we started to talk about differences in life expectancy between socio-economic groups by using examples that many people are now familiar with the such as the bus journey/bus stop analogy.
However, despite its success I think that life expectancy data was not sufficient to mobilise and sustain action at a local level. Some of the reasons for this might be that life expectancy:
- feels very far off – it does not feel sufficiently urgent to decision makers and service providers.
- as a measure does not reflect the profound impact that long term inequality has on health and wellbeing – it simply does not bring you into the room to feel the day to day life of living in circumstances of financial insecurity, poor housing etc.
- a short life can still feel to be a relatively small part of someones total life years and therefore may feel as though it is not a very big deal to some people.
Health Inequalities and Multi-Morbidity – a more powerful narrative
In recent times thanks in significant part to the Institute of Health Equity and other players such as the Health Foundation we are seeing a shift to focus more on the impact of health inequality on Disability Free Life Years and multimorbidity.
This useful table from a RCGP article on the epidemiology of multimorbidity in primary care sets out the ten most prevalent morbidities and associated comorbidities
Table from Epidemiology of Primary Care (2018) by Anna Cassell, Duncan Edwards et al.
The graph below from the Institute of Health Equity shows how people who experience socio-economic inequality are likely to have a shorter period of disability free life expectancy than people who are wealthier and to already have poor health before they reach pension age.
Talking about the relationship between socio-economic inequality and Disability Free Life years (or the very similar multi-morbidity) is helpful because it:
- speaks directly to the NHS – in particular primary care (as is shown by this useful recent study in the British Journal of General Practice) because many of these conditions are amenable to clinical treatment.
- motivates local commissioners because there is a relationship between multi-morbidity and use of urgent care.
- brings a helpful focus on Mental Health particularly anxiety and depression
- is a greater motivator to action because it affects people earlier and for longer – so it feels more meaningful and relevant
- allows us to ask other questions such as why are people not accessing treatment or adhering to it – which drags the NHS into discussions about the social determinants of health
- opens up a debate about the role of the social welfare system and how the NHS connects with it because they both have a role in helping people live independent lives when they experience disability and illness.
Of course focussing on multi-morbidity does not in itself solve health inequalities – however it does challenge the NHS, make it clearer what it’s contribution can be and pushes health services to make stronger connections to agencies working to address the social determinants of health.
What do you think?