Public health - topics: Tackling health inequalities
The health of populations in industrialised countries in many ways has never been better (World Health Organization 2008). However these health gains are not shared equally by all members of society. Wealthier people tend to live longer and lead healthier lives than people in lower social classes. For example “even excluding the poorest five per cent and the richest five percent, the gap in life expectancy between low and high income is six years” (Marmot 2010, p.37). Other differences, such as ethnicity, gender, sexuality, age, area, community and religion also affect life chances.
The socioeconomic determinants of health have long been recognised. How central this is to future improvement in health is a point which is made forcefully in the review Fair society, healthy lives by the Chair Professor Sir Michael Marmot - “this link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus” Marmot 2010, p.3). A Royal College of Nursing (RCN) publication provides an overview of the impact of social determinants of health and underlines the part that nurses play in recognising this impact and working to address it (RCN 2012).
Working for Health Equity: the role of health professionals
The RCN is also one of more than 20 health organisations that have made a commitment to act in support of a landmark report Working for health equity: the role of health professionals published in March 2013 (UCL Institute of Health Equity 2013a). The report demonstrates that “the health care system and those working within it have an important and often under-utilised role in reducing health inequalities through action on social determinants of health” and launches a new programme of activities to tackle health inequalities through action by health professionals (UCL Institute of Health Equity 2013b, p.7). The report presents the evidence base for actions and makes recommendations on how this can be achieved, illustrated with case studies that show effective action that is already in place (UCL Institute of Health Equity 2013c).
UK agendas
Not surprisingly tackling health inequalities is a key concern of public health policies across the UK.
- In Wales a key action in Our healthy future focuses on tackling health inequities (Welsh Assembly Government 2009), and a strategic action plan has been developed to address this (Welsh Government 2011). Local Health Boards will be expected to explain each year how health inequalities are narrowing (Welsh Government 2012).
- In England the independent review on health inequalities identified the six policy objectives and the action required around these to achieve reductions in health inequalities (Marmot 2010).
- NHS England, working as part of the NHS Equality and Diversity Council, has invited views to inform the development of a strategy to promote equality and reduce health inequalities which will embed the principles of the NHS Constitution and the NHS Change Model (NHS Change Model 2013; NHS England 2013).
- In Scotland the Equally well implementation plan acting on the report of the Ministerial Taskforce on Health Inequalities sets out "an ambitious and radical programme for change across the key priority areas of: children’s very early years; the big killer diseases of cardiovascular disease and cancer; drug and alcohol problems and links to violence; and mental health and wellbeing" (Scottish Government 2008, p.2). The emphasis is on effective early intervention.
- An Audit Scotland report had made a number of recommendations for the Scottish Government and Community Planning Partnerships highlighting the need for greater clarity in allocation of funding at local level, clearer measures of progress and cost effectiveness, and greater clarity around the roles and responsibilities of different organisations to maxmimise partnership working.
- In Northern Ireland a ten year strategy is also informed by the Marmot review. It puts forward a rationale for a whole systems approach - a coherent approach across all government departments and beyond - prioritising "a more systematic and structured approach to addressing the reciprocal nature of health and other Government policies" (Department of Health Social Services and Public Safety 2012, p.54).
Common themes across the UK countries include the importance of interventions early on and the need to give children the best possible start in life, and in particular recognition of the potential impact of different social determinants and how they influence health at different stages of life. A “commitment to learn from the best available evidence of what works in tackling equalities in health” (Scottish Government 2008, p.10) is echoed by the other countries, for example a key task of the Marmot review was to identify “the evidence most relevant to underpinning future policy and action” (Marmot 2010, p.4).
Also highlighted across the different policy and implementation documents are the structures and systems for implementing policy and initiatives with recognition that “complex, multifaceted and collective action is required” (Welsh Assembly Government 2009, p.13). For example, in Wales a unified public health system has been developed with Public Health Wales providing the specialist public health support (Public Health Wales 2010).
In England reforms to the health system, which commenced in April 2013, see local authorities taking the lead in improving health and tackling health inequalities. The aim is for local authorities to maximise the health benefits in all policies as "many of the social determinants fall within their ambit" either directly or through existing and new partnerships (Department of Health 2011, p.2).
Partnership working and cross-sector collaborations are important. Healthy Places, Healthy Lives is a partnership programme which helps to reduce health inequalities and improve population health (NHS Institute for Innovation and Improvement 2012).
The website that developed from the Marmot Review ‘Fair Society Healthy Lives’ and related work on health inequalities, has case studies and reports that illustrate different kinds of initiatives that are tackling health inequalities. These are arranged according to themes relevant to different social determinants such as preventing and treating ill health and disadvantage, social exclusion and vulnerability (UCL Institute of Health Equity 2013d).
References
The items referenced below were last accessed on 19 April 2013. The majority are in PDF format - see How to access PDF files.
Audit Scotland (2012) Health inequalities in Scotland, Edinburgh: Audit Scotland.
Department of Health (2011) Local government leading for public health, DH website. (One of a number of documents detailing the new public health system).
Department of Health, Social Security and Public Safety (2012) Fit and well: changing lives 2012-2022. A 10-year public health strategic framework for Northern Ireland: a consultation document, Belfast: DHSSPS.
Farrell C et al (2008) Tackling health inequalities – an All-Ireland approach to social determinants, Dublin: Combat Poverty Agency / Institute of Public Health in Ireland. Made available by The Health Well.
Improvement and Development Agency (IDeA) (2010) Year of Healthy Communities Calendar: April 2010 to March 2011, IdeA website.
Marmot M (2010) Fair society, healthy lives: Strategic review of health inequalities in England post 2010 (the Marmot Review), UCL Institute of Health Equity.
NHS Change Model (2013) NHS Change Model website.
NHS England (2013) Creating a personal, fair and diverse health and care service: survey guide, Redditch: NHS England.
NHS Institute for Innovation and Improvement (2012) Health places, healthy lives, NHS Institute website.
Public Health Wales (2010) Local public health, Public Health Wales website.
RCN (2012) Health inequalities and the social determinants of health (PDF 397.3KB) (Policy briefing 01/12), London: RCN.
Scottish Government (2008) Equally well implementation plan, Edinburgh: Scottish Government.
UCL Institute of Health Equity (2013a) Working for Health Equity: the role of health professionals. Commitment to action from Royal College and other organisations (PDF 706.9KB), London: The Institute.
UCL Institute of Health Equity (2013b) Working for Health Equity: the role of health professionals. Full report, London: The Institute.
UCL Institute of Health Equity (2013c) Working for Health Equity: the role of health professionals: Case studies from the report (PDF 772.2KB). London: The Institute.
UCL Institute of Equity (2013d) Themes section of the website (select themes tab).
Welsh Assembly Government (2009) Our healthy future: technical working paper, Cardiff: Welsh Government.
Welsh Government (2011) Fairer health outcomes for all, Cardiff: Welsh Government.
Welsh Government (2012) Together for health: a five year vision for the NHS in Wales, Cardiff: Welsh Government.
World Health Organization (2008) Responding to the challenges of a changing world, WHO website.