Health

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We should live in a society that delivers health equity. This is 'the absence of unfair and avoidable or remediable differences in health among population groups, defined socially, economically, demographically or geographically'.

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Fairness and health equity

Achieving health equity (the absence of health inequalities between different groups in society) is a matter of fairness.

There is a 'social gradient in health': the lower a person’s social position, the worse his or her health. People with different levels of income and other social circumstances experience avoidable differences in health, with the better off living longer lives in better health than the disadvantaged. This is unfair. The relationship between social inequality and health inequality is so strong that the magnitude of health inequalities is a good marker of progress towards creating a fairer society.

Part of this is about the delivery of healthcare: everyone in the UK should be able to access high-quality care to support them to attain mental and physical health and wellbeing. But the more important issue is tackling the social determinants of health, the non-medical factors that influence health outcomes. These are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. Tackling these broader issues is the best way to prevent ill-health and promote wellness and wellbeing. Prevention is cheaper than cure, and there is both an inarguable moral case and a compelling economic case for investing in health equity and in the social infrastructure that enables it, and which supports individuals in living healthy lives.

The pandemic reinforces what we already know. We can’t keep people healthy if they don’t have a roof over their head and food on the table.

Bechara Choucair, Chief Health Officer, Kaiser Permanente

Tackling health inequalities

Unfair health outcomes nearly always result from unfair access to opportunities and unfair inequalities in our society. According to the World Health Organisation, sectors outside health have a bigger impact on population health outcomes than the health sector itself. This is not widely understood by the public, despite the excellent work of Sir Michael Marmot and others. Tackling health inequalities does not require a separate health agenda so much as a broader societal agenda. We need to focus on all of the 'social determinants of health', including income, housing, upbringing, education, work and the environment, and focusing on improving opportunities and living standards for everyone (the idea of ‘proportionate universalism’, based on universal rather than targeted interventions, but with a scale and intensity that is proportionate to the level of disadvantage).

The more favoured people are, socially and economically, the better their health. 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.

The healthcare system

The NHS (and local government and voluntary sector) can also play a key role, by investing more in preventing ill-health and tackling inequalities in access to healthcare services, and ensuring that the availability and quality of healthcare and health promotion services in deprived areas (or targeted at disadvantaged groups) is as high as in more prosperous parts of the country. Funding for prevention and tackling health inequalities could be freed up by improving productivity and reducing costs in the NHS (in areas such as contracting, procurement and reducing agency costs). The NHS should continue to contract the private sector to deliver some clinical and non-clinical services as long as they are timely, free at the point of use, high quality and delivered efficiently.

What needs to change

Given that most actions to reduce unfair health outcomes involve addressing non-health issues such as income inequality, housing and education, most of the changes proposed below are beyond the scope of the NHS. However, the NHS should also be investing more in health promotion and the prevention of ill-health, including promoting healthy diets and exercise (i.e. the demand side), as well in ensuring that any inequalities in the delivery or availability of healthcare services (the supply side) in different regions or to different groups are tackled.

The Marmot 2021 report on COVID (Build Back Fairer) repeats key themes of the 2010 and 2020 reports on health inequalities, arguing for seven priority areas for action:

  • Reducing inequalities in the early years (including by increasing spending on years provision to improve availability and quality, and increasing pay for childcare workers)
  • Reducing inequalities in education, with a focus on equity in funding decisions and increasing attainment levels (including by restoring per-pupil funding, increasing access to laptops, making exam grading more equitable, rolling out catch-up tuition, providing additional support for pupils with special needs and excluded pupils)
  • Increasing fairness for children and young people, with a focus on poverty, mental health and education, employment and training (including by reducing child poverty levels to 10%, improving mental health support in schools, increasing the number of training schemes and apprenticeships, and increasing funding for youth services)
  • Creating fair employment and good work for all, by providing a more generous minimum wage for everyone in work and a minimum income for those not in work, tackling poor-quality work and precarious employment, and improving work-life balance.
  • Ensuring a healthy standard of living for all, by putting health equity and wellbeing at the heart of local, regional and national economic planning and strategy, making the tax and benefits systems more progressive and the latter less punitive, and eradicating food poverty.
  • Creating and developing healthy and sustainable places and communities, by increasing local government funding in deprived areas, tackling air pollution in deprived areas, building more good-quality homes that are affordable and environmentally sustainable, increasing support for those in the private rented sector, reforming council tax, reducing homelessness and extending protection against eviction.
  • Strengthening ill health prevention, by building a public health system that focuses on acting on the social determinants of health and health inequalities, with more funding (0.5% of GDP, with spending focused proportionately across the social gradient).

A recent COVID impact report by the Health Foundation (Unequal pandemic, fairer recovery) outlined the opportunity for "a new settlement between the state, individuals, the third sector and business" with the goal of improving health and reducing inequalities at its centre. It suggested that action was needed in two areas:

  • Immediate action to address the harm caused by the pandemic and prevent longer term scarring effects. This includes tackling the health care backlog, increasing mental health support to help people back into work, protecting family finances, creating jobs, and ‘catching up’ education and training.
  • Building resilience for the longer term. This includes putting in place an adequate safety net to cope with future income and health shocks, providing greater protections for low-paid workers, designing better quality jobs, creating stronger communities and investing in higher quality public services to put prevention first through the government’s levelling up agenda.

It also suggested that change is not just about additional spending, and that the government can place a greater focus on using resources wisely, joining up initiatives across government and taking a ‘prevention first’ approach to enable better spending through local government. It recommended that in making decisions about allocating spending, greater weight needs to be placed on longer term, preventative measures and health and wellbeing gains.

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Health and fairness

Health equity does not translate to absolute equality of health outcomes, because it recognises that some people will enjoy better health at various times in their lives than others for reasons that cannot be avoided or remedied (including aspects of both nature and nurture). But it does suggest that everyone should have the same opportunity to live a healthy life, and that any unfair or avoidable differences in health outcomes should be eliminated. This means, firstly, that good quality healthcare should be equally available to everyone, regardless of their ability to pay, and with priority given to those in greatest need (the founding principles of the NHS), even if some people choose to pay for private treatment that is either better or quicker. But it also means that the underlying causes of poor health, such as poverty and poor housing, must be tackled. Failure to do this will result in a failure to prevent the inequitable burden of ill-health falling on the most disadvantaged in society, which is both unfair and inefficient (since cure is always more expensive than prevention).

Health inequalities that can be prevented reasonably easily are unfair, and removing them is a first step in building a fair society. We need to move away from a situation in which the more disadvantaged in society not only die sooner, but also spend more of their shorter lives with a disability or in ill health. The ‘social gradient of health’ means that the higher someone’s social position and income is, the better their health will be, and this gradient is steep. Creating a fairer society in which health inequalities have been minimised will make this gradient shallower and so improve the health of almost the whole population, as well as ensuring a fairer distribution of good health across it.

Learning from other countries

In general in developed countries, high levels of wealth inequality lead to high levels of health inequality. This manifests itself in a huge number of ways. For example, overall rates of stillbirth in the UK are higher than in a dozen comparable countries. International comparisons show that life expectancy is inversely correlated with income inequality: life expectancy in the UK is lower than many countries where the share of national income taken by the richest 1% is lower than in the UK (such as Japan, Spain, Norway, France and the Netherlands).

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The authors of The Spirit Level combined a range of indicators (life expectancy, infant mortality obesity, teenage births, homicides and so on) into an 'index of health and social problems', and found a strong positive relationship between high scores on this index and high levels of income inequality across a large number of developed countries, with the UK scoring near the top on both axes. A similar relationship was found between the UNICEF index of child wellbeing and income inequality (although in the other direction, since wellbeing is a positive measure). The UK scored at the bottom of this table in 2007 (the 2020 update showed the UK scoring 27th out of 38 rich countries).

The lesson that the UK can learn from other countries, then, is simple. Building a fairer society, in which income inequality is lower than its current very high levels will improve health and wellbeing and will reduce the prevalence and severity of a wide range of health and social problems across society, but with an especially large effect on the most disadvantaged.

The situation today

Leading health think tank The King's Fund summarises some of the most extreme examples of health inequalities in Britain today:

  • Men living in the most disadvantaged communities can now expect to live for 9.5 years less than those living in the wealthiest areas, while for women, the difference is 7.5 years.
  • People living in the most deprived areas spend nearly a third of their lives in poor health, compared with only about a sixth for those in the least deprived areas.
  • In early 2020 black men were 3.3 times more likely to die from COVID than white men.
  • A child in year six in the most deprived part of the country is twice as likely to be obese as their counterparts from the most well off areas.

Health outcomes across society have, of course, worsened dramatically as a result of the COVID pandemic, partly due to its direct impacts and partly because of its indirect impacts on people's physical and mental health and wellbeing and on the prevention and treatment of other health conditions. However, the impact of COVID on the most disadvantaged in society has been particularly acute, and has highlighted the importance of pre-existing health and social inequalities. In Build Back Fairer, Michael Marmot made the case that "conditions and inequalities in key areas of life prior to the pandemic – including education, occupation and working conditions, income, housing communities and health itself – relate to England’s high and unequal mortality rate from COVID-19".

The report showed that rates of mortality from COVID-19 in England between March and July 2020 were double in the most deprived areas compared with the least deprived, and that there was a clear gradient in mortality rates related to deprivation. It also demonstrated strong links between living conditions and COVID mortality.

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Looking beyond the pandemic, there are many signs that different groups in the population experience unfair health outcomes compared to the rest of society. The EHRC's 2018 report Is Britain Fairer? outlines some of these for groups sharing various protected characteristics:

  • Some groups experience worse physical and mental health outcomes than the rest of the population, particularly homeless people, transgender people, Gypsies, Roma and Travellers, refugees and asylum seekers and people with learning disabilities. These are linked with poorer socio-economic outcomes for these groups, which exacerbate poor health.
  • On average, the life expectancy of women and men with a learning disability is 18 years and 14 years shorter than for non-disabled women and men, respectively.
  • Lesbian, gay and bisexual people, and those reporting other sexual orientations were almost twice as likely (27.2%) as heterosexual people (14.3%) to report poor mental health in England.
  • 45% of all looked after children in England have a diagnosable mental health condition (compared with 10% of all children).
  • In 2016/17, known rates of Mental Health Act 1983 detention in the Black or Black British group were over four times that of the White group, and rates of Community Treatment Order use were almost nine times those of the White group. The use of restrictive interventions on mental health service users is also over three times higher for Black or Black British groups compared with White British.
  • In England and Wales, Pakistani and Black African groups had the highest infant mortality rates and the Other White ethnic group had the lowest rate. This pattern has continued since 2009. Infant mortality rates were higher in the most deprived areas compared with the least deprived areas in both England and Wales and increased risk of infant mortality is associated with higher levels of maternal deprivation. Infant mortality, the risk of which increases with deprivation, rose in 2016 for the first time in decades.

The same report also highlighted inequalities in accessing health care for some groups:

  • People with learning disabilities and disabled people more broadly, homeless people, refugees and asylum seekers and Gypsies, Roma and Travellers continue to experience the most significant barriers to accessing healthcare services.
  • Rules governing eligibility to NHS healthcare in England are inconsistently and often incorrectly applied by healthcare providers, resulting in refugees and asylum seekers being wrongly refused access to healthcare.
  • Transgender people experience considerable barriers to accessing specialist services in England and Wales, and regularly face poor treatment and discrimination when accessing general health services.

Health inequalities for black and minority ethnic communities in the UK are particularly stark compared to the rest of the population. A recent report found that black women are four times more likely than white women to die in pregnancy or childbirth in the UK, and women from Asian ethnic backgrounds face twice the risk. The Runnymede Trust's 2021 report on race and racism in England found that BME people with learning disabilities die younger than their white counterparts, with a 26-year difference between white and BME people with profound and multiple learning disabilities. It also found that, had the white population experienced the same risk of death from Covid-19 as black groups, there would have been an estimated 58,000 additional deaths between March and May 2020.

The UK government is starting to produce more detailed data on health equity and social determinants of health, which should produce useful comparative data over the coming years, including Public Health England's wider determinants data and the ONS Health Index.

The Marmot Review in 2010 showed that people living in the poorest areas of England died on average seven years earlier than those in the richer areas, and that the average difference in disability-free life expectancy was 17 years. The 2020 follow-on review found that, for the first time in more than 100 years, life expectancy had failed to increase across the country, and that for the poorest 10% of women it had actually declined, with an overall widening of health inequalities since 2010 and an increase in the amount of time people spend in poor health. The 2020 report found large regional differences in health outcomes, including in life expectancy, with an increase in the north/south health gap, and an increase in child poverty since 2010, which is also higher than in other European countries (22% compared to Europe’s lowest rates of 10% in Norway, Iceland and the Netherlands). The report blamed many of these worsening indicators on reductions in public spending and the availability and quality of public services, such as the closure of many children’s and youth centres, reduced funding for education, a worsening housing crisis, and more people with insufficient money to lead a healthy life, with unequal cuts that affected more deprived areas the most.

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