Health disparities white paper

 

Health disparities white paper

Doing a fair few talks at a fair few meetings on “what are we doing, or going to do about health inequalities” or similar. 

Note here. Steal / use as you want to

NB – I don’t know what is IN the forthcoming White Paper. Here are some of my thoughts and hopes.

 

1            introductory stuff

Language and framing

What to call it

Lots of discussion and questions from field at the recent LGA / ADPH conference on what we “call it”.

Everyone in the field calls it “health inequalities”.

There is something on use of language to appeal to different audiences – the recipient of a message may be more willing to hear some framing and language than others.

Don’t just think of “health”. Disparities in health, inequalities or any title is an economic issue. Poor productivity and impact on health and vice versa 

 

Models of evidence

We also need to move on from individualised model of evidence – Lynch and Marmot make the point about avoiding medicalisation and medical model answers (see his points re poverty vs methadone (better “evidence” for methadone, but may lead us the wrong way).

We over-pathologised inequalities and are over relying on policies based on technocratic or economic/fiscal solutions? That said just making people angry wont be enough either.

 

What is “an intervention”

We also need to move on from our standard view of “intervention”. See my thread here re providing support to those addicted to gambling vs challenging the whole framing of gambling, or seeking to eliminate the influence of industry. All are “interventions” two of the above are substantially more potentially impactful.

 

Getting the political framing straight

How to appeal to the right politically speaking, needs thought

Put thought into how it is framed; for example whether to focus on equality of opportunity or outcomes, levelling up v redistribution; whether the mention macro economic and socio-political issues that may exacerbate; how to land inequality in the context of the health / economy narrative.

 The economic argument is thus

Multimorbidity (more than one NCD at once) more common than single morbidity, it is also more common in working age people than older. It is also strongly associated with exit from paid employment - characterised as a shift from paid employment to unemployment, disability benefits, economic inactivity or early retirement

NCD is common and a common cause of lost productivity. See the 2018 CMO / IFS report and the 2018 NHSA Health for Wealth report, and my own 2018 DPH report. I also touched on with more data in this blog. Finally this piece by Les Mayhew was a good analysis linking health, pension, benefit and productivity policy.

This becomes and issue of family income and poverty, benefit system cost, and lost economic productivity. 

All of the above is unequally distributed and those with least health in the first place have most to gain compared to those with average or above average health (law of diminishing marginal returns).

Health service interventions are important and there is plenty of evidence of impact. Prevention of illness in the first place is even more important.

Stigltz argues we wont get near solving the economic growth problem until we solve the economic inequality problem. One might extend this to a health outcome context – we wont solve the population health issue (and thus health & social demand as a subset) until we make progress in the health inequality space

 

Not just SDOH

Don’t just think of inequalities in a model of social determinants but also commercial. In fact maybe frame the whole space in the political determinants of health outcomes into which fit commercial, social, economic.

 

Framing health disparities more widely. The tie to govt aspirations on levelling up are hugely important

I wouldn’t go much beyond the analysis in the Levelling Up white paper with a side helping of the IFS / Deaton work on economic inequality

 

This  podcast interviewing Deaton and Paul Johnson on economic (& other) inequality is insightful. Ditto this Briefing Room on Levelling up. The key points here:

·       Devolution of power and £ to region & local

·       Power & centralization. Govts like power and wont give it up

·       Transport ....HS2/ Cancellation of other transport investment. Will this help level up or not.

·       Skills matter

·       Cities matter, but don’t only think of this ins that context

·       Where’s health in analysis (& policy focus)

·       Where’s HMT? Other govt depts not in and or actively opposing or policies that have opposite effect 

Will Hutton: ·       “The white paper itself is scathing about the consequences of too much political centralisation, the constant chopping and changing of centralised policies and an ever more complex pot pouri of competitive mini pots of money that need to be stitched together locally for a coherent whole.”

·       “Getting  levelling up right is a £2.5Tn economic opportunity, we need to be prepared to take it and mobilise and integrate the six capitals (human, financial, intangible, physical, institutional and social) that together drive growth. No great economy can be built on a weak society; no great society can be built with a weak economy – and both need inspired local leadership.” 

 

The IfG analysis of missions was also helpful. Some are more clearly articulated than others, some are more aspirational than others. Arguably we all have a responsibility to help government clarify and implement their ambitions. 

 

Urgency - Is there the right level of urgency

We threw EVERYTHING at the pandemic (rightly). The impact of inequality is 6 times as great as the pandemic see Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge. The impact of COVID-19 on life expectancy is substantial (−5.96 years) if unmitigated, but over a decade the life expectancy impact of inequalities is around six times greater than even an unmitigated pandemic

 

How long will it take. Realism on how long it will take to close the health gap on current trends
The current inequality is 100 yrs at least in the making, it wont be done in 8 years, esp with current levels of investment (see below on money). Yet we talk about within a generation or within the next 8 years. To get this gap closed within a generation is “ambitious”.

We all know a long term, generational approach is needed. The Briefing Room analysis set out that it took Germany 30yrs to get 75% of job done

Realism of the aspiration on HLE goal in levelling up.  We WERE on trajectory of 1yr improvement every 4rs, thus take 20 yrs to add 5yr to life expectancy. However we all know LE is currently flatlining. But politically and investment wise we would need to reverse austerity. See this excellent thread from Jo Bibby – on current trajectories it would take 75 years to close the gap in health.

 

Short, medium, long term interventions must be in the mix.

Many say that only by delivering short term is there freedom for long term. Of course this is true but the  challenge is that we may never get beyond short term, and short term often focuses on “individuals” (more countable and measurable) not structural.

 

don’t neglect the lessons from the past  / looking to the future

Marmot 10 years on is as good a summary as you will see of the telling of the story of the last decade or so. My note on key points here. Each chapter gives a detailed commentary on what has happened over the last 10 years in a structure broadly similar to the original report.

 

The key points of Marmot 10 years on for me - 1) Poverty matters, 2) Place matters, 3) Gender differences are stark, 4) Healthy life expectancy declining, 5) the slowdown in health improvement more rapid and severe in the U.K, 6) more data is needed on ethnicity, 7) inequalities in health not inevitable, 8) we know what to do, 9) a strategy is needed to coordinate cross govt action key. Led by No 10, not DHSC

This from the Kings Fund on lessons from efforts over decades on inequalities is very helpful.

From this piece of work by the Kings Fund. Things to think about include: 1) Lack of institutional memory, 2) we prize novelty over persistence and endurance, 3) we DO need a national framework, 4) investment in tools and support for local.

 

The same piece also set out why efforts falter

Embed in systems beyond cycles and fads. Multi generation legacy

Portfolio of effort over s/m/l term

Make it hard to NOT focus on inequalities – align money, support, payment, goals, purpose

Build on momentum of covid

Focus on disruption. Yes embed what works, also disrupt.

 

2            What to “do”

a bucket list of policies

There is no shortage of policy prescriptions, but take care with a cookie cutter approach. There is a never ending search for the perfect policy list. Marmot wrote a pretty good list a decade ago. At place level, the recommendations from the Marmot GM report is excellent, whether Marmot is or isnt current flavour the work done over decades now provides as good an evidence base for “what to do” and “how to do it”.   Many are wanting very specific asks - and specific is quite hard in this one. There are lots of policy bucket lists  - see especially the third in this series of blogs setting out the key points of many evidence based reviews. That said, important to not over simplify into a tick list. Something important about hold onto the complexity.

 

The NHS and inequalities

Health inequalities is 20% health, 80% wider determinants. That said the 20% still matters; and b) the 20% may be more quickly and directly influenceable. Who is REALLY challenging the NHS on what THEY are doing around things that are in DIRECT NHS control. The extent to which the machine is putting managerial effort into fixing people or creating health and within that overtly orienting its efforts on creating health in those who have least of it. There are plenty of specific NHS oriented recommendations: 

·       The Deep End manifesto - Primary care oriented stuff

·       The Chris Bentley stuff is excellent, also here for a place based spin. NHS oriented in focus, heavy emphasis on implementation and coverage of interventiosn. It remains excellent.

·       The (what I call the) “Dave Buck 8”

·       Core 20 +5 etc

·       Lots of potential for specific pieces of work around big risks – CV clinical risks, cigs and booze, coverage of vacc and screening and other routine preventive services.

Important in this space to not forget the conversation about hard to reach popupations vs difficult to access services (NHS and all other).

 

Emblematic policies vs a more fundamental approach

The White Paper may be seen as a tool for a smallish number of emblematic policies, or as something much broader. There is obviously nothing inherently wrong in the use of a White Paper to push forward on a smallish number of high profile policies.

In this there is something about incremental changes in lots of spaces and service delivery areas vs fundamental shifts. We mustn’t neglect either – aggregation of marginal gains AND changing the rules. However it is easy to get lost in many small projects and not focus on the leverage points.

 

3            flipping the purpose of the  machine matters as much as the bucket list

The real business end of this is flipping the machine and some of the more sprawling stuff.

 

Who is responsible for “health” and health inequalities

The Health Foundation have been writing on this recently - A matter of life and death. Explaining the wider determinants of health in the UK. Similarly the Health Foundation blog on public understanding of health and health inequalities sets out a concise explanation of all that is wrong about how we frame health policy.  

Of course need to get out of the narrative on "health inequality" OUT of something rooted (only) in NHS framework. LE and HLE is often framed as an “NHS thing”. (it is about death, illness and health, thus it MUST be about the NHS etc). My sense is almost all of govt see LE as “something the NHS does”.  This is plain wrong. 

 

Where you locate it / Who owns it. DSHC vs whole of government

How are all govt departments in the mix on tackling this. The treasury, No 10;, what is the ask on different govt depts.- HMT, DfE, DfT, DCMS, DHCLG, HO, DWP – what are EACH of the other depts doing. This also plays out locally, and underscores the importance of whole of society place based responses. Each govt department needs to take responsibility for the impacts their policies have on human health and wellbeing. This requires leadership from MPs and pressure from the public and civil society.

 

Who holds it all together . Who is accountable for the healthy life expectancy gap, how is that accountability executed

For me this is a key q. And a hard one to pin on a specific person and role.  When I ask people often stare at me. That said I don’t have the management muscle or resourcing to be in all the places I need to be.

Everyone wants to “own it”. Is there a single controlling mind? Do we WANT to go down space of single controlling mind. Single system controller of a complex adaptive system

I have written a bit on cross government (local and national) accountability at the end of this blog (HT Carolyn Wilkins for the idea)

 

Do we see health inequalities as a set of projects or part of the central purpose.

Currently we certainly doesn’t invest in resourcing and management capacity to implement the necessary interventions. Heath inequalities is mostly (in my experience) left to “something for public health to sort”. 

Is the machine of the institution prepared to treat inequity of outcome as something as important as elective recovery and financial balance. And put the same level of managerial effort in

People do (rightly) want neat tidy projects. Hard to do. Given the sprawling nature of what contributes to 1) health, 2) the gap in health outcomes.

 

Beware of perversity

machine says it really wants to “address inequalities” but other bits of the machine often operates in a way that is contrary to this. Some examples

we usually focus on the overall number at population level (NB remember the numerator AND the denominator), or on the population mean and not the distributional nature. The difference between offer and outcome / who is turning up vs who isnt.

A classic example of this is vaccine and screening coverage (covid and beyond), ditto screening. Focus of the performance regime has been overall numerator and coverage, not focus on middle aged Asian men with diabetes in in the more deprived oarts of our places, or people with a disability.

 

are we prepared to go to multi year and multi sector scope for return on investment.

Single year & within single  sector accounting will not solve this problem

 

are we prepared to address inequity in resource allocation.

Another classic example is the whether resource allocation formulas are sufficiently weighted to ensure there is inequitable funding for basic public service delivery matched to inequitable need or demand.

Within public sector (well beyond NHS and care) are we prepared to do reallocation. This is basically a shift from a model of funcing that prized equality to a model of funding that prizes equity - unequal funding matched to unequal need.

Primary care is a well researched example of this. Not sorting this will systemically worsen inequalities.

As a recent example see this story on the Shared Prosperity Fund – “Oxfordshire will receive a 12% funding boost, funding for Hampshire and west Surrey will remain the same, while Berkshire faces a cut of just 4%. Meanwhile, Leeds will see a funding cut of 43%, Manchester 35%, Liverpool 34%, and the north-east of England 37% overall”

There are doubtless plenty of others across many public services.

 

Test yourself against the Marmot recommendations and principles

How well do we apply the Marmot principle the original Marmot 6 principles (here to remind you: 1) Give every child the best start in life, 2) Enable all children, young people and adults to maximise their capabilities and have control over their lives, 3) Create fair employment and good work for all, 4) Ensure a healthy standard of living for all, 5) Create and develop healthy and sustainable places and communities, 6) Strengthen the role and impact of ill-health prevention)

to every aspect of public and private state. Maybe part of the job is testing and assessing the state of response against specific evidence based recommendations and working out state of play / what does better look like. So in any conversation about any aspect of business – ask how will this close the gap, if it doesn’t close the gap please publicly explain the rationale for proceeding.

 

What CAN be measured

Take care re aggregate / population improvement that ignores the gap and the floor.

The machine MUST focus the performance system onto the gap and outcomes not offer. In this dont forget protected characteristic groups, ie not just socio economic (even if it is harder to measure)

There are lots of good health outcome frameorks out there. I rarely stray away from Fingertips and the public health outcome framework.  

 

4            there are (at least) three elephants in the room

 

Where is the money

You cant address inequalities without investment. Either new investment to level up whilst holding the top steady or redistribution of existing investments. Obviously this then brings into focus the tie with levelling up is oh so obvious.

 

In my view the analysis part was excellent, the commitment to action less so. This  podcast interviewing Deaton and Paul Johnson on economic (& other) inequality is insightful. Ditto this Briefing Room on Levelling up. Similarly the Will Hutton analysis on levelling up.

 

Germany committed to spend €2 TRILLION over 25yr to level up E/W - £70bn a year (we are committing £1.2bn). The level of investment in UK trivial compared to Germany (3% of GDP quantum of £ as additional investment)

 

Ronaldo’s Instagram account versus the gap in outcomes

A colleague sent me a note saying that Ronaldo earns £1.7 million for each Instagram post. About 10 Ronaldo Instagram posts is more than Yorkshire gets for its entire regional funding income via the shared prosperity scheme. His salary for actually playing football isnt included in this. Have a look at some of many celebrities’ Instagram posts, some of them are promoting things that aren’t terribly healthy for us or the planet.

I am not sure we can achieve the ambition without investment. 

 

LA funding base / decay of social safety net in both welfare system and LA service response

Local gov finance cant be ignored in the analysis and prescription around levelling up, disparities and similar. It is hard to conclude this hasn’t had an impact. The IFS review of local gov finance is one of the best analysis of what has been happening, there are both implications in this for the social determinants of health (alternatively known in local government as “core services” and equity, considering how this played out in different parts of the country - those with most need been hit hardest.

 

All the analysis points in the same way:

Ben Barr and colleagues on long term trends in Loc Gov spending also highlights similar.

Marmot 10yr on, Bambra et al - long term trends in life expectancy over 2 decades (LE is now decreasing in many places)

The  IfG further highlighted the same issue - All English local authorities had reduced spending on such provision since 2010, the report found, but the extent of this varied from a 5% cut in East Sussex to 69% in Barking and Dagenham. TDLR - England’s most deprived areas have seen largest local spending cuts

Barr et al documented the impact of LA spending cuts on Life Expectancy (and by definition HLE)  Local government funding and life expectancy in England: a longitudinal ecological study

The most recently the analysis of ONS on health state life expectancies by national deprivation deciles, England: 2018 to 2020 (Health Foundation comment here, Guardian here).

 

Poverty and cost of living matter. A lot

The Resolution foundation set out that the typical working-age household will experience a 4% fall in income, £1,100, in 2022-23. The same analysis found that the scale and distribution of the cost of living squeeze means a further 1.3 million people are set to fall into absolute poverty next year, including 500,000 children – the first time Britain has seen such a rise outside of recessions.  The high income may not notice, it will be REALLY noticeable for those on low incomes. See the example in here of a single parent, with one child, working 20 hours a week at a low-to-medium wage.

 

This article in the Guardian was one of the better pieces I saw on the link between cost of living, poverty and health. The poorest people in the UK are about to experience a fresh wave of such indignities. There are three critical considerations 1) the differential effects of losses as against gains; 2) relative and absolute poverty; 3) and the value provided to people by welfare and public services – the social safety net. The psychological impacts will bleed into physical impacts, particularly mediated by long term cortisol response, agency, a sense of self-worth, and participating in networks of family and friends. As the Food Foundation has noted, for those on a low income they would have to spend 75% of their weekly income only on food to eat the “recommended” diet. It is not ignorance or the inability to cook that is the problem. It is poverty.

 

The President of the Faculty of Public Health set out that child poverty  also has to be central to any approach to tackling health disparities. She stated that childhood poverty is rising in the UK, but the government continue to ignore it, that the legally binding targets for reduction of child poverty (2010 Act) were abolished after the 2015 general election by introduction of the Welfare Reform and Work Act 2016, and that the Act also revoked the government’s obligation to produce a Child Poverty Strategy and similar obligations for local authorities, thus removing any legal incentive for local or national government to address child poverty.

 

This paper and the associated editorial neatly set out recent evidence that rising child poverty rates might be contributing to an increase in children entering care. Children's exposure to poverty creates and compounds adversity, driving poor health and social outcomes in later life. It is well documented that being taken into care follows patterns of socio economic deprivation. This all drives service demand, financial risk and poor outcomes, a vicious cycle. Thus it is hard to conclude poverty can justifiably be excluded from any comprehensive approach to talking inequality.

 

 

5            Summary

We all know covid shone light in structural inequalities  AND highlighted importance of place based approaches. There is a huge amount to support in the Govt ambitions around levelling up, we all know delivering those ambitions will be difficult and, well, ambitious.

We all know it is here where the root of health inequalities lies.

We should seek to leverage the new structures – in role and purpose, we should seek to value and embed an equity focus in all our institutions and to develop governance systems and metrics to embed the right programmes.

We should seek new partners. People have different things to bring to the party and different angles on old problems, and recognise the broad problem affects all sectors in different ways. Obviously we shouldn’t neglect old partners. We need to continue to strengthen community based and asset based approaches.