Reducing health inequalities, even in affluent areas, needs to be a priority for government and society, say Sian Griffiths and colleagues
As Theresa May stood on the steps of Downing Street on her first day as prime minister she drew attention to the challenges of health inequalities:
“Right now, if you’re born poor, you will die on average nine years earlier than others. If you’re black, you’re treated more harshly by the criminal justice system than if you’re white. If you’re a white, working-class boy, you’re less likely than anybody else to go to university…..”
A recently published report on the State of Child Health has further evidence on the relevance of socioeconomic circumstances and their impact on children’s health. It makes clear that health strategies need to take account of and act to reduce inequalities at global and local levels.
Oxfordshire may well be regarded as a part of the country where health inequalities are not a problem, as it is an area most often represented by dreaming spires and country houses of the great and good, but data and experience tell us otherwise. Within the county, depending on which area you come from, there is a stark mismatch in life expectancy of up to 10 years, and six wards are in the lowest decile of children in England living in poverty. Families with dependent children still face homelessness despite the overall prosperity in the county, and children with free school meal status are more likely to be lower educational achievers. This once again highlights that the unmet health needs of children and young people go beyond clinical care, and reducing health inequalities needs to be a priority for government and society.
Whilst we often focus on the needs of the most vulnerable it is not, as emphasized by Michael Marmot in his seminal report “Fair Society Healthy Lives,” just the gap between the rich and the poor that matters, or the absolute level of deprivation, but the gradient itself. This insight shows that narrowing inequalities not only helps those with the poorest health, but also improves the health status of all communities including the seemingly affluent. Enduring inequality in health outcomes is an ongoing result of injustice in society, and lives are cut short earlier than they should be. Inequality matters because, as a robust and growing body of evidence shows, the populations of societies with bigger income differences tend to have poorer physical and mental health, more illicit drug use, and more obesity.
We also need to overcome the “prevention paradox,” by which we mean the tendency for prevention and wellbeing to take a lower priority in people’s attention and funding allocation compared to the more immediate “fire-fighting” acute emergencies that overwhelm the hospital sector.
Recognising variation and deprivation is an important issue for all areas, no matter how affluent they are. Oxfordshire Health and Well Being Board (HWBB), stimulated by Oxfordshire Clinical Commissioning Group (OCCG), established an independent commission to examine exactly what local health inequalities exist and what must be done to address them. The objective was to raise the profile of health inequalities in Oxfordshire and inform strategic planning and operational delivery by gathering evidence from multiple organisations and individuals in the county to advise on tangible actions.
The first task for the commission was to work out how to go about producing recommendations that would make a difference. The process we followed was one based heavily in transparent and open public consultation—with submissions invited both in writing and at public meetings around the county. Whilst the commission heard evidence, the audience (who spanned different parts of society and age groups) were encouraged to join in the discussion and “evidence testing.”
The Commission presented its recommendations to the HWBB in November 2016. The key message is that unacceptable inequalities in health persist in Oxfordshire, and that these inequalities affect the whole of society. The causes of health inequalities span factors much wider than those solely within the remit of the health system, and so our recommendations consider what can be implemented by the whole breadth of services in order for positive change to occur. This, we would argue, is an example of how HWBBs can serve their original purpose, in removing organisational barriers and serving the local population independent of organisational silos.
One particular concern of the Commission was that this report, however worthy its recommendations are, would be either unread or not acted on by those in positions of power. To be effective, the huge challenge of addressing health inequalities needs to be taken seriously by all partners in the county, and this is the cornerstone of our recommendations: the need to adopt a Health in All Policies approach.
However we also know that better data than are currently available are needed to make our arguments and drive forward this approach. The gap in data on black and ethnic minority groups in the county was a particular issue, as was the lack of communication between different stakeholders to provide coordinated and accurate data for key cross-organisational indicators. As well as gaps in quantitative data, difficulties accessing and engaging with underprivileged communities meant that these voices were not always heard during the consultation process.
Knowing the tight financial constraints imposed on the county are probably equal in size to the ambition for change, commissioners knew the recommendations needed to be “aspirational yet do-able.” For example, OCCG is being asked to review how its current allocations address inequalities and to consider not only redistribution of resources but also whether a joint “inequalities fund” could be established within existing margins to develop innovative local interventions. The CCG recognises and is positively engaged with the fact that small investments made now to improve people’s health could mean savings in the long term. Crucial to the success of such an initiative is a shared investment and shared benefit across health and local authorities.
Aware that many people failed to maximize their benefits, the commission suggests the work of the Citizen’s Advice Bureau, who are working collaboratively with the CCG to provide access to advice within some GP surgeries through their “Benefits in Practice” scheme, should extend across the county. The local acute trust are also including the recommendations of the Commission in their public health strategy for the coming years, firmly committing to embed the concept of health inequalities into their future work.
So will the Commission and its report make a difference? The process ran in parallel to the Sustainability and Transformation Plans that were being drawn up which outline plans for a geographical area that extended beyond the county borders. STPs have been widely criticized for being developed behind closed doors without the input of wider stakeholders, and we had to rely on having commissioners who were also part of that process to take the inequalities lens with them into these discussions. Drawing the commissioners from different sectors has however allowed the recommendations to be debated in their organisations. For the time being, the report is “in play,” but without vigilance the pressures of budgets and performance are likely to crowd it off the agenda. The spotlight needs to be repeatedly shone on the need to monitor and address health inequalities in the county. The challenge remains to make addressing inequalities an integral part of policy making and its implementation, not only at a local but also at a national level.
Sian M Griffiths, Institute of Global Health Innovation, Imperial College London.
Emily Phipps is an academic clinical fellow in Public Health in Thames Valley Deanery and a previous National Medical Director’s clinical fellow.
Joe McManners is clinical chair of Oxfordshire Clinical Commissioning Group (OCCG). He is also a GP at Manor Surgery, Headington, and trains GPs. He was previously a Oxford City Councillor with responsibility for housing. His priorities for the commissioning group are to integrate the health and carer system and to prioritise tackling health inequalities.
Competing interests: SG and JM none declared. EP was a contributing author on the Oxfordshire Health Inequalities Commission Report and has previously worked for Oxfordshire County Council in her capacity as a public health registrar.