The impact of inequality and poverty on health is increasingly recognised both within the NHS and among think tanks and policy makers.
It is important to catch this wave – this focus and interest is unlikely to last so we must make gains now to lay foundations for lasting change.
The new report by the Kings Fund on the NHS role in tackling poverty is an example of this. Over the last few years the Kings Fund has shown a growing interest in this area – although it still feels like a comparatively marginal activity in its work.
Their report is based on gathering together examples of existing practice in the NHS. This take us so far – but it misses some key elements that are essential for change to be long lasting. I wonder if the structure of the report has been constrained by contractual requirements from NHS England?
The biggest section that is missing in this report is asking and answering this simple question:
“Why should the NHS be concerned about poverty?“
If this is not addressed confidently and explicitly then we have not created a framework to have this debate within the NHS…… and a debate needs to happen.
The idea that clinical practice should be informed by the experience of poverty is still seen as irrelevant or at best a side issue by too many clinicians and directors of services
It is the Health Foundation who are doing the heavy lifting here.
The graphic below is from a Health Foundation article that sets out some of the reasons why the NHS should be interested in poverty. In essence it summarises some of the points made by Marmot in particular.
I think that there are three reasons why the NHS should be concerned about poverty
- if you are experiencing poverty you are more likely to be unwell and have multiple morbidities
- poverty means that you will find it harder to access services because they are too often allocated unfairly or are provided in a way that does not make it easy for you to use them because of where or how you live.
- a significant health problem creates financial insecurity and means that you need to use health services as effectively as you can – yet your poverty will make it hard to focus on getting well because you will be having to tackle financial problems such as debt or housing insecurity at the same time as trying to use NHS services effectively.
I summarise this in the poisonous Venn diagram below.
Over the years on this blog I have given examples of how a catastrophic health problem such as Cancer, Major trauma, Psychosis brings together this toxic mixture of financial insecurity, need for health services and difficulty in using them.
This combination is much more likely to make tough and resilient people vulnerable – it affects them AND it affects NHS services effectiveness. Here are two really good examples of work on this North East and Cumbria NHS – Poverty Proofing Health Settings and the Money and Mental Health Policy Institute.
I think we need to have a more systematic focus across health services generally, asking the question:
“where are some of the most vulnerable people in our hospitals and communities and do our clinical services reflect this need?”
Two final points.
It is dispiriting to see yet another report on poverty that devotes almost half of its suggested actions to the role of the NHS as an economic anchor. Yes, the NHS could do more on its role as a local economic engine – but putting it in this report is a mistake for two reasons.
First, the primary function of the NHS is its clinical responsibilities – giving this much space to the economic role takes attention away from this – imagine how barren this report would have been without this section? Frankly, we need that absence just to demonstrate how much further the NHS needs to travel here.
Second, we need a more considered analysis of the impact that economic anchors have on poverty. How much effect do they really have? Are there solid examples of where they have directly contributed to reducing or stemming poverty? It is too easy to get excited by the big money numbers without thinking … how much of this money actually ‘trickles down’ to those experiencing poverty.
Finally, we really do need to start talking more clearly about the role different parts of the NHS have with regard to the poverty agenda. We tend to default to just talking about community based services like General Practice and not give enough attention to the acute sector.
What do you think?