Since 2010 there has been a steady stream of legislation, policy initiatives and reports, all intended (in some cases purporting) to tackle health inequalities – which are by definition unfair and avoidable, causing immense damage not only to many of our citizens but to the economy and social fabric of the country too.  In the words of Michael Marmot:

The UK is the sick man of Europe. Since 2010, improvements in healthy life expectancy have stalled, health inequalities have been increasing and health for people living in the most deprived areas has been getting worse. The country has been struggling with three big challenges: a decade of austerity, the Covid-19 pandemic and a cost-of-living crisis. Each of these has exposed a grim fact: Britain is an unhealthy place to be poor, even relatively poor. https://www.theguardian.com/commentisfree/2023/apr/24/labour-wes-streeting-nhs-britain-europe

The causes are multiple and crucially they extend well beyond what the NHS can deliver. From the cradle to the grave our lives are influenced decisively by the three pillars of social injustice – unfair distribution of wealth, unequal opportunity, and a failure to recognise privilege. People experience them for no reason other than other people choosing not to act to prevent them.

These injustices are institutionally baked into our lives from cradle to grave- in maternity, in early years, in school and college, in housing, in transport, justice, employment (and unemployment), environment and of course, access to care within the NHS. Scarcity reduces intellectual bandwidth https://www.theguardian.com/books/2013/aug/23/scarcity-sendhil-mullainathan-eldar-shafir

The imperative to tackle health inequities is a powerful and well-evidenced one. The work of Marmot and the attention by others on the impact of inequalities on specific groups (e.g. BME populations, the poorest communities, disabled citizens for example) or arising from particular circumstances (e.g. Covid) provides the basis for a powerful narrative around the impact on individuals and the wider impact on our economy and society.

Despite this there are multiple obstacles to overcome:

• A “levelling up” policy that refuses to accept that class, ethnicity, or gender, for example, are crucial determinants for life opportunities.
• Essential resources in public health and local government that have been hollowed out and deprioritised.
• Siloed working which frequently undermines addressing health inequities.
• An NHS funding model that remains overwhelmingly focussed on diagnosis and treatment of illness in secondary care and not on prevention or early intervention in primary and community care.
• The skills and knowledge essential to being proactive and preventative in population health are in short supply.
• We still too often victim-blame and refer to minority communities as “hard to reach” instead of “under-served”.
• There is an absence of sustained inter-sectoral accountability for tackling the root causes of inequality – despite opportunities to learn from experiences internationally where government, healthcare organisations and local authorities are held accountable for delivering culturally safe environments and assessed on their progress towards achieving health equity
• One example of such an approach is the Australian National Agreement https://www.closingthegap.gov.au/ on losing the gap that embeds real partnership between Aboriginal and Torres Strait Islander peoples and the national , state and territory and local authorities on the design and delivery of policies, programmes and services that affect them., focused on better life outcomes.  It acknowledges that to close the gap, it is necessary to take a human-rights based approach to health ensuring that Aboriginal and Torres Straight Islander peoples determine, drive and own the desired outcomes, working alongside all governments as equal partners. https://humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/projects/close-gap-indigenous-health

Despite all these obstacles, there are some positive initiatives across the country, sometimes drawing on the NHS as an anchor institution, that signpost the art of the possible.

• Lewisham and Birmingham, for example, are working jointly on race and health inequality. https://www.birmingham.gov.uk/info/50266/other_public_health_projects/2309/birmingham_and_lewisham_african_and_caribbean_healthinequalities_review_blachir
• Sussex, which has substantial pockets of deprivation and health inequality, use their Integrated Care Strategy to recognise that multiple factors influence a person’s health (socio-economic, health behaviours, health care and physical environment) and action work through The Sussex Health and Care Assembly to facilitate joint working to improve outcomes, access and patient experience for communities across Sussex. https://www.sussex.ics.nhs.uk/wp-content/uploads/sites/9/2023/01/0438-NHS-Sussex-VF4-4.pdf

But how do we unpick and challenge the biases baked into our society that impede sustained equitable improvement in population health and tackle workforce inequities in the NHS?

We suggest four key actions are needed:

1. Debiasing systems and processes and not primarily relying on debiasing people.
2. Board accountability for ensuring equitable health outcomes underpinned by data, scrutiny, and challenge whether through nudges or more direct means.
3. Strengthening inclusive leadership by making leaders personally responsible for challenging discrimination especially those aspects of discrimination and inequality that prove the hardest to shift – notably race and disability – and promoting leaders who act as active allies, role-modelling the behaviours and attitudes they expect of others.
4. Ensuring that the workforce and leadership reflects the diverse communities that the NHS serves and takes action to listen to the voices of those impacted by inequity.

 

 

We need a new approach to tackling health equity and social justice in the NHS, avoiding ineffective implementation that wastes scarce resources, disengages staff, and leads to distrust within minority communities – this is neither affordable nor sustainable. Interventions that are implemented poorly have unintended consequences that set us back on our collective goal to improve population health and promote health equity.

Therefore, we need to make sure that:

• There is a powerful case for tackling health inequity – one that benefits individuals, society and the economy as a whole and articulate this in as powerful a way as possible.
• Those seeking to tackle health inequalities work in a joined-up way, with a shared understanding of how to tackle bias and discrimination, addressing barriers to accessing care, ensuring equitable distribution of resources and services, implementing cultural competency for all health professionals, and co-producing new services with underserved communities.
• Organisations create and sustain competent leadership – at every level – supporting people who are inclusive, passionate, and prioritise this work both in wider communities and in their own workplaces.
• Mobilisation around health equity and patient safety, drawing on community insights especially from patients, users, and workers and research intelligence to debias access and treatment, increase transparency, triangulate data and focus on prevention and continuous improvement.
• Recognise that change requires Board accountability and moving towards a national regulatory body accountable for achieving health equity.

Health inequalities are intimately linked to social justice t.  https://www.bmj.com/content/371/bmj.m4049

We need to put back into the heart of the health and care system a deep sense of values (empathy, kindness, respect, care, meaning) so that everyone experiences this daily in all they do and we need to recognise and unlock the untapped potential that exists if we focus more attention on upstream initiatives in prevention and addressing the root causes of inequalities. https://centreforpopulationhealth.co.uk/about-us

Authors

Roger Kline is Research Fellow at Middlesex University Business School.

Dr MaryAnn Ferreux is Executive Medical Director, Health Innovation, Kent Surrey Sussex.

Prof Durka Dougall is Founder of the Centre for Population Health.

Randeep Kaur Kular is  Director of Strategic Projects at University Hospitals Birmingham where she leads on the delivery of large-scale complex projects, programmes, and portfolios and is the tactical lead for Health Inequalities. She has previously worked at the Runnymede Trust, the Office of the Deputy Prime Minister, the Cabinet Office and the Department of Health.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.