Health inequalities - what to “do”. What are the actions or interventions we should implement?

This is the second in a series. The first blog set out some background, context, language and framing issues. Here I set out some thoughts on intervention. Again, it’s a little fiddly.

General principles & Framework

There are a number of different evidence based approaches to what we can do, such as those produced by Marmot, Due North or our own Strategy, to name just three. This needs to be put into a framework, and a decision made regarding how to focus. See blog 1 for some thoughts.

For example a framework could develop around behaviour, determinants, communities, health and social care. It could also be framed around the life course (starting well, living well, ageing well), or in terms of services for people and places where people live. Any serious effort to address health inequalities must start with inequalities in outcomes around employment, income and housing and wealth inequality/ownership of capital.

There are a number of recurrent themes in a discussion on general principles:

Resist single silver bullet answers: all domains need answers and solutions. Everyone wants pithy answers: they don’t exist. Marmot’s recipe still stands and hasn’t been beaten. There isn’t a single intervention – policy or service wise – that will crack this issue;
Most are unconvinced that “writing plans” will solve or make much progress. As above, measurement is easy, and talk is easy, but concrete progress is difficult. Whilst we probably don’t need to measure progress on indicators with ever finer grain detail, we DO need to ensure that implementation of interventions is robustly monitored. There is something to consider regarding the underlying narrative and whether we really believe it, also something around an organising principle to be hardwired into organisational DNA rather than a standalone plan (while accepting someone somewhere might occasionally need to do something);
Complex system: one of the things that has hindered progress is the size and complexity of the issue. Progress may depend on the interplay of national and local government policy, with aspirational and practical actions for local players. In addition outcomes are a complex interplay of health; wealth; education; poverty; family etc. All interact in ways we often don’t fully understand but all matter, and can’t really be adequately addressed in silos. This is compounded by the fact that progress in this area is NOT the path of least resistance, especially at times of shrinking budgets;
Influence by proposition: splitting the agenda into actionable chunks might help but not letting sight of the whole is equally important. Health inequalities are cross cutting not “owned”. We need to think how to frame cross cutting issues in ways that have traction across and within silos. This leads to questions such as: What and who do we want to influence? What do we want in terms of resource, power, and permission?

PHE guidance is helpful. System, scale, sustained effort.

Consider those areas that have seen real change. It’s mostly a combination of doing different stuff better (transformation) or / and sustained effort to do the right things, at scale, over a long time (aggregation of marginal gains).

Recently PHE guidance – reducing health inequalities: system, scale and sustainability – set out a revision of the DH Health Inequalities National Support team work

Key points:

intervening at different levels of risk – phsysiological (BP, cholesterol), behavioural (smoking), psychosocial. All interconnect. All need attention. Don’t neglect one at the expense of others
intervening for impact over time
intervening across the life course – start well, live well, age well. Direct link to Marmot themes.
to have real impact at population level, interventions need to be sustainable and systematically delivered at a scale in order to reach large sections of the population. Reach and coverage of effective high impact interventions in populations.
In medical terms most of the gap is made up of CVD, respiratory, Cancer – thus think of prevention in the context of risks for those broad areas,

Not just service level

Intervening at civic, community and service levels can separately impact on population health. In combination, the impact will be greater.
- Civic interventions – through healthy public policy, including legislation, taxation, welfare and campaigns can mitigate against the structural obstacles to good health. Adopting a Health in All Policies approach can support local authorities to embed action on health inequalities across their wide ranging functions.
- At a community level, encouraging communities to be more self-managing and to take control of factors affecting their health and wellbeing is beneficial. It is useful to build capacity by involving people as community champions, peer support or similar. This can develop strong collaborative/partnership relationships that in turn support good health.

Specifics
General

Multiple authors and commissions have published many detailed specific and generic recommendations and policy prescriptions. Each prescription has merit and there is some overlap between different publications, while many of the recommendations are of relevance to national agencies, some to regional agencies, and some to local agencies. Some of the national recommendations may be localisable (either directly or through devolution).

Some interventions are within SCC control, some are within the city’s control and some are NOT within immediate control. We should consider “the ask” of our services and policy areas, and what cuts across many services or portfolios.

A simple prescription is not possible, but the following themes are commonly cited:

Differential resourcing: this is the disproportionate distribution of resources, services and assets to meet disproportionate need (and inequitable outcomes). It is unknown whether the distribution of resources (wrapped into service delivery or otherwise) and assets reflects the patterns of need. In NHS delivery there IS a mismatch, and the challenge is to disproportionately invest in a generalist offer matched to need levels. We don’t know the extent to which this story is reflected across sectors within the economy.

This may not ONLY be a debate about “resources” defined narrowly or broadly, but also about the right policy framework and coverage of effective interventions. In a net zero new cash environment, there may be merit in exploring mechanisms for addressing resource inequity: hold top and level up vs level down vs some other version of how the principle is operationalised. Whatever mechanisms are used the need is to focus the greatest resources where need is highest, and not disinvest as it is more expensive improving outcomes in the populations with most need;

Re-look at the economic impact of inequality: GVA vs broader social benefits. Inclusive growth vs sustainable economy. Addressing inequality is NECESSARY for economic growth. There will be merit in relooking at the public sector supply chain in this and how well we really enact social value in our commissioning, inclusive growth & sustainable economy, living wage and our role as employer around skills and jobs. In this area the wealth gap is (by far) the most important, however not easily or quickly resolvable. This obviously lends itself to the narrative on inclusive growth, and that may be a more effective line to pursue;
Community capacity and power: some call this “community development”. Some have suggested that the various strategies for community capacity building (PKW, Neighbourhoods and others) are too small, marginal, insecurely funded and not well enough connected. There may be merit in relooking at how we commission volcom organisations, and what our expectations are of them both in terms of service delivery and in terms of voice and capacity development. Linked to this, but not just in this domain, is the focus on a needs (the needs of the marginalised) vs assets (scope of opportunity) approach and a greater sense of coherence across areas. Some of the key issues here are financial insecurity, anxiety about not being in control of where they live (‘social cohesion’) and a cynicism about local services. Our strategies are a mixture of responding to crisis and jam tomorrow (employment); we often miss out the bit in the middle: addressing current insecurities and vulnerabilities;
Inequality and poverty are obviously inextricably linked and might be viewed as different lenses on broadly the same issues. All of absolute poverty (not having money makes a difference), relative poverty (the size of the gap between best and worst) and the floor threshold (mustn’t fall below) are important. On relative measures, we need to compare mean and median income for instance, as both measures can tell different stories;
There is a clear case for investment in debt advice, cheap credit & welfare rights for those most financially vulnerable, in the context of welfare reform. The welfare budget dwarfs the NHS (£215 billion spent in 2015/16 on social welfare support including pensions, or £125 billion on means tested and disability benefits); it IS a determinant of health and is likely differentially affecting the most vulnerable. Relatively little effort is put to understanding need in this space; for example, the level of problematic debt among key populations. The tax and benefit system is certainly affecting child poverty and living standards have got worse for families with kids. Recent IFS figures projected that the 2015 budget will mean the income for families with children will get worse at a level proportionate with starting income, i.e. it is regressive making the lot of the worst off worse;
Participation in education and generating aspiration is important. Investment in children’s outcomes is a long term infrastructure investment for economic prosperity. “That’s not for kids from round here”. Kids often have high ambitions until they are 13 or so, then those ambitions are dulled. The job is keeping them with high ambition through to career. The opposite is to deliberately create the equivalent of “pushy parents”. Demanding, wanting the best, articulate a different vision of the future. Hunger for learning that drives self-esteem and attainment. There may also be a case to reconsider the pathways into work especially those looked after, care leavers, no qualifications, learning disabled. The role of multi academy trusts needs consideration. Some will get this agenda, some may not. See here – for an example of capacity development across a large number of schools.

Evidence base. Health inequalities evidence based policy prescriptions and interventions. What to do?

This section presents a summary based on available sources of evidence – ie it is evidence led, rather than idea led.

There is no shortage of policy prescriptions and ideas. This document isn’t necessarily complete, many will find glaring holes, thus should be viewed as work in progres

Effort make to ensure ideas are positive not patronising, life course focused, and focus on structural interventions
Effort made here to focus on issues with local traction, some national ideas included – become targets for advocacy.
Interventions need to focus on services for people, places where people live and structural policy interventions.

Considerations in evidence led approaches

One overarching issue common to all the evidence reviews is that upstream policy measures to reduce material poverty and deprivation are crucial to prevent extreme social and health inequalities from occurring in the first place, this fact is often overlooked in the “evidence base”, thus evidence around “poverty” is equally as important as evidence around “health inequality”

How this evidence is interpreted depends on whether a social or medical model of health is taken (arguably both are relevant); and the timeframe in which results are expected.

Marmot

Marmot 2013 remains the most valid and comprehensive guide

Reminder of key messages

Gradient matters AS WELL as the most vulnerable. Proportionate universalism
Injustice itself is a risk.
Economic benefits of addressing – productivity loss, tax receipts, welfare payments, treatment costs
Social factors; fairness and distribution of power; access to meaningful work; wages, taxation and cost of living; education, training and employment, housing, public transport and amenities; Social and community networks; Individual lifestyle factors; Healthcare
The specific recommendations of marmot are NOT included in the table below, but noted in full further in this document

Marmot set out that reducing health inequalities will need action on 6 policy objectives:

Give every child the best start in life

reduce inequalities in the early development of physical and emotional health, and cognitive, linguistic, and social skills.
Ensure high quality maternity services, parenting programmes, childcare and early years education to meet need across the social gradient.
Build the resilience and well-being of young children across the social gradient.

Enable all children young people and adults to maximise their capabilities and have control over their lives

Reduce the social gradient 1 in skills and qualifications.
Ensure that schools, families and communities work in partnership to reduce the gradient in health, well-being and resilience of children and young people.
Improve the access and use of quality lifelong learning across the social gradient.

Create fair employment and good work for all

Improve access to good jobs and reduce long-term unemployment across the social gradient.
Make it easier for people who are disadvantaged in the labour market to obtain and keep work.
Improve quality of jobs across the social gradient.

Ensure healthy standard of living for all

Establish a minimum income for healthy living for people of all ages.
Reduce the social gradient in the standard of living through progressive taxation and other fiscal policies.
Reduce the cliff edges faced by people moving between benefits and work.

Create and develop healthy and sustainable places and communities

Develop common policies to reduce the scale and impact of climate change and health inequalities.
Improve community capital and reduce social isolation across the social gradient.

Strengthen the role and impact of ill health prevention

Prioritise prevention and early detection of those conditions most strongly related to health inequalities.
Increase availability of long-term and sustainable funding in ill health prevention across the social gradient.

The remainder of the blog sets out policy or intervention ideas led by multiple reviews of evidence over last 10 years.

Domain

Intervention

Overarching

Source

Marmot, Smith

· Introduce further national targets for reducing health inequalities

· Routinely undertake health equity impact assessments on all policy in areas, including macroeconomic and fiscal policy, trade policy, foreign policy, ‘defence’ policy and international development

· Pursue ‘Health in All Policies’ style approaches to policymaking

· Pass responsibility for reducing health inequalities to a central government office, rather than to departments of health

· Implement measures to protect the policy process and decision-making from interference by relevant commercial sector interests

· Include socio-economic status as a protected characteristic of Equalities legislation

Tax / benefit, income

Source

Picket, Smith, McAuley, Baum, Marmot, British Academy, NHS Scotland

· Progressive systems of taxation, benefits, pensions and tax credits that provide greater support for people at the lower end of the social gradient and do more to reduce inequalities in wealth.

· A 10% increase in the level of tobacco taxation.

· Introduce a minimum price for alcohol products via minimum unit pricing

· Institute measures to reduce economic inequity including more progressive income tax and taxes on wealth and inheritance. Tax capital gains at the same rate as income tax. Introduce a cap on the wealth that any one individual can inherit

· Introduce a tax on high sugar and high fat foods

· Increase social protection for those on the lowest incomes and provide more flexible income and welfare support for those moving in and out of work (‘flexicurity’) – review of the systems of taxation, benefits, pensions and tax credits to achieve the reduction of ‘cliff edges’ faced by those in and out of work and facilitate flexibility of employment

· Review the role of the tax and benefits systems to facilitate adherence to minimum income for healthy living standards

· increase in the minimum wage.

· Increase income support to the unemployed to a liveable level

· Universal Basic Income

· Require the highest paid employees of a company to earn no more than 20 times the salary of the lowest paid employees.

· Hypothecate (earmark/ring-fence) portions of taxes on health-damaging products (e.g. tobacco, alcohol and petrol) for investment in health improvement, especially in poorer areas

Vulnerable populations

Source

Picket, Luchenski, Marmot

· More resources in support for vulnerable populations, by providing better homeless services, mental health services and other social care.

· Upstream policy measures to reduce material poverty and deprivation are crucial to prevent extreme social and health inequalities from occurring in the first place…..

· Caseworking support and combination intervention approaches boost effectiveness in most groups.

· Evidence for specific interventions for excluded young people is scarce, some evidence for fostering and mental health/criminal behaviour

· Respite care (ie, short-term recuperative care for homeless individuals after hospital discharge) can reduce the number of future hospital admissions and use of emergency departments in homeless populations

· Provision of housing improves a range of health and social outcomes for homeless populations, particularly among those experiencing mental illness and substance use disorders.

Children, families, best start, primary and secondary education

Source

Smith, Baum, Marmot

· Dramatically increase investment in public early childhood education and affordable, quality childcare. focus on early development of physical and emotional health, and cognitive, linguistic, and social skills.

· Provide routine support to families through parenting programmes, children’s centres and key support workers

· Increase the proportion of overall government expenditure allocated to the early years and ensure this expenditure is focused progressively across the social gradient

· Introduce policies which intensively focus on improving literacy among primary school children in deprived areas through one-to-one teaching for those with low reading scores

· Invest more resources in state-funded education, with additional investments for schools serving more deprived communities

· Target long-lasting contraceptives at young women in deprived communities

· Provide paid parental leave in the first year of life with a minimum income for healthy living

· Provide means-tested, state-funded childcare (similar to Sweden)

· Prioritise reducing social inequalities in pupils’ educational outcomes.

· Prioritise reducing social inequalities in life skills – Extending the role of schools in supporting families and communities and taking a ‘whole child’ approach to education, Consistently implementing the full range of extended services in and around schools,

· Developing the school-based workforce to build their skills in working across school– home boundaries and addressing social and emotional development, physical and mental health and well-being.

· Foucs on building the the resilience and well-being of young children across the social gradient.

· Support families to achieve progressive improvements in early child development – Giving priority to pre and post natal interventions including intensive home visiting, Providing paid parental leave in the first year of life with a minimum income for healthy living, Giving routine support to families through parenting programmes, children’s centres and key workers, to meet social need via outreach to families

lifelong learning

Source

Picket

· View lifelong learning as a crucial investment and make all public education free

· Reduce subsidises to private education. Require fee-paying (private) schools to allocate at least 50% of their places for non-fee paying children living in deprived communities

· Provide easily accessible support and advice for 16-25 year olds on life skills, training and employment opportunities, delivered through centres that are easily accessible to young people

· Provide further work-based learning for young people and those changing jobs/careers, including paid apprenticeships

· Ensure access to higher education is affordable (e.g. by getting rid of tuition fees where they are in place)

· Increase the availability of non-vocational life-long learning across the life course

Employment and work

Source

Picket, Marmot, Picket,

British Academy, Smith

· More resources for active labour market programmes to reduce long-term unemployment and for in primary care health services in deprived areas to support routes to work. Make it easier for people who are disadvantaged in the labour market to obtain and keep work.

· increase social protection for those on the lowest incomes and provide more flexible income and welfare support for those moving in and out of work.

· Tackling Health-Related Worklessness: a ‘Health First’ Approach. Reconsider “work” as a clinically relevant outcome

· Create public sector jobs to engage people at all stages of the lifecycle, and focus on job creation

· Encourage, incentivise and, where appropriate, enforce the implementation of measures to improve the quality of work across the social gradient, – Ensuring that public and private sector employers adhere to equality guidance and legislation, Implementing guidance on stress management and the effective promotion of well-being and physical and mental health at work.

· Develop greater security and flexibility in employment – Improving flexibility of retirement age, Encouraging/incentivising employers to create or adapt jobs that are suitable for lone parents, carers and people with mental and physical health problems.

· Improve implementation of measures to improve the quality of work across the social gradient – Improving job security built into employment contracts and ensuring employers adhere to equality legislation, extending stress management and the effective promotion of well-being and physical and mental health at work.

· Ensure all public and private sector employers adhere to equality guidance and legislation

· Encourage and incentivise employers to create or adapt jobs that are suitable for lone parents, carers and people with mental and physical health problems

· Encourage and incentivise union membership and/or the development of worker co-operatives

· Introduce stronger employment legislation, including greater support for trades unions and restrictions on ‘flexible’ insecure contract

Homes and housing

Source

Smith, Baum

· Support an enhanced home building programme including in decent social housing to bring down housing costs.

· View having a secure home as a right for all

· Fuel poverty strategy. Improve the energy efficiency of housing across the social gradient. Provide subsidised fuel or fuel supplements for those on the lowest incomes to address fuel poverty

· Repeal recent ‘bedroom tax’ legislation

· Enhance the existing “Right to Sell” so that mortgagees have the right to stay in their home and become tenants rather than face eviction

· Amend legislation so that illegal actions by landlords and banks that deprive people of their home become criminal rather than civil offences

· Introduce rent controls (which would also reduce housing benefit bills)

· Increase the taxes that apply to second homes, holiday homes and empty commercial property

· Extend the current council tax bands up to band Z with a view to transforming the tax into a fairer national land and property tax

Transport and travel

Source

Picket, Smith, , British Academy, Baum

· Reduce speeds in urban areas, starting with the poorest areas, especially to protect children and the elderly.

· Create healthy urban environments which are safe, friendly to pedestrians and cyclists, and which encourage social interaction

· Changes in the extent of active (walking and cycling) commuting to and from work

· Provide (or maintain, where already provided) free public transport for people past the retirement age (to prevent social isolation)

· Provide free public transport for all children

· Increase taxes on petrol and diesel

Economic

Source

Baum, Marmot

· Measure what we treasure and no longer rely on GDP as the measure of our progress. Instead, introduce a well-researched measure of wellbeing appropriate to our country

· Encourage small and medium-sized businesses which show commitment to the local communities in which they operate

· Determine which assets and resources should be either nationalised or privatised based on demonstrable long term public benefit

· economic strategies should include an explicit aim to reduce income inequality gaps.

· Develop inclusive growth strategy to stimulate local ecoomiy, within this public service anchor institutions have significant role.

Health care

Source

Smith, NAO, Baum, McAuley, PAC 2010

· Invest more resources in primary care health services serving very deprived areas. address the GP shortage in the areas of highest need, This inequity in the resource allocation for General Practice creates structural inequality. imbalances in the funding received by individual practices (relative to need),

· Invest more resources in support for vulnerable populations, by providing better homeless services, mental health services, etc.

· Deep end Manifesto –. A good a place to start. Needs to be turned into specifics

· increase the prescribing of drugs to control blood pressure by 40 per cent, cholesterol control similar

· double the capacity of smoking cessation services – especially in a focused targeted way

· Greater provision of alcohol brief interventions (ABIs).

· Ensure universal access to high quality and appropriate, publicly-funded health care, and progressively make community-controlled primary health care the backbone of our system. This system will focus on cure, rehabilitation, prevention and promotion

· Invest in the evaluation of new medical technologies to ensure they have more benefits than costs

· Eliminate subsidies to private health insurance and invest funds in the public health system

· address the low proportion of NHS budget (<4%) allocated to prevention.

· Models of care focused on burden of disease and population, not service focused, and a focus on populations, neighbourhoods and communities that is organisationally agnostic is more likely to be pro equity than the current model.

· START with need and use equity audit to highlight inequity between need, service use and outcomes. Approach to equality to go beyond protected characteristics (ie in the legisltation) and cover with equal weight the other aspects of vulnerability (deprivation, homelessness, abuse). Tool to focus on the people we aren’t reaching. Need to be more granular and precise in identifying who the target population is beyond the catch all “hard to reach”.

· Agree and enact a principle of a disproportionate offer and resourcing (to meet disproportionate need). Measurable indicator is financial – what % of the NHS £ is witin primary care.

· Role of NHS as economic anchor. Don’t neglect the notion of inclusive growth, a sustainable economy and the role of the NHS as an economic anchor institution. This in itself is worth further work as has many facets.

Other

Source

Smith, British Academy, Baum, Marmot

· Fluoridate domestic water supplies (where this is not already done)

· Building Age-Friendly Communities

· Prioritise policies and interventions 1 that reduce both health inequalities and mitigate climate change – Increasing active travel across the social gradient, access and quality of open and green spaces available across the social gradient, Improving local food environments across the social gradient

· Reduce the availability of tobacco products (both legal and illicit)

· planning controls that ensure the most unhealthy food is not so readily available in the poorest places, tax on sugary drinks – perhaps hypothecated for research into behavioural insights on who still smokes and why

· Restrict lobbying by powerful interest groups by creating a transparent register of lobbyists, and capping donations to all political parties. Regulate corporate behaviour so that transnational corporations can’t externalise costs of poor occupational health and safety, environmental degradation and unsafe and unhealthy products. measures to protect the policy process and decision-making from interference by relevant commercial sector interests (e.g. alcohol, tobacco and ultra-processed food manufacturers and retailers

· Make our policy development processes as participatory as possible, and encourage groups with little economic and social power, in particular, to be meaningfully engaged. Using Participatory Budgeting to Improve Mental Capital at the Local Level

Other specifics re food, alcohol, tobacco control

MUP, or alcohol tax increases, Restrict the availability of alcohol products via further licensing restrictions, further restrictions on the marketing of alcohol products (e.g. ban on TV advertising), complete ban on the advertising of alcohol products, Provide incentives for retailers in poorer areas to promote healthier food products, Ban trans fats in all foods, Provide free, nutritious school meals for all children in state schools, Restrict advertising of ultra-processed / high fat / high sugar food and drinks (e.g. introduce a ban on TV advertising before the watershed), Implement a complete ban on the advertising of ultra-processed / high fat / high sugar food and drinks, Increase the price of ultra-processed / high fat / high sugar food and drinks via taxation, Reduce the availability of tobacco products (both legal and illicit), Increase the price of tobacco products via tax increases, Introduce standardised packaging of tobacco products (i.e. remove branding), Legislate for smoke-free cars, Legislate for smoke-free homes

References

Picket https://peg.primeeconomics.org/policybriefs/population-health-reduction-of-health-inequalities

Marmot – http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

Smith et al – https://www.ncbi.nlm.nih.gov/pubmed/25174045

British Academy. http://www.britac.ac.uk/publications/if-you-could-do-one-thing

Public Accounts Committee 2010. https://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubacc/…/470.pdf

NAO – https://www.nao.org.uk/report/tackling-inequalities-in-life-expectancy-in-areas-with-the-worst-health-and-deprivation/

McAuley A http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159256

Baum – https://croakey.org/beyond-the-social-determinants-a-manifesto-for-wellbeing/

Luchenski,- inclusion health, what works http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31959-1.pdf

NHS Scotland – Modelling the impact of policy interventions on income in Scotland –

Glasgow / Deep end