This is a collective statement on behalf of SHA bringing together public health evidence and other opinions on a key Covid policy issue.

The impact of the pandemic on inequalities more generally and the implications for policy and plans going forward

Key messages

  • The pandemic has hit us when we have already seen health inequities widen
    • 10 years of austerity have disproportionately affected the least affluent and the most vulnerable
    • Life expectancy has plateaued and inequalities in mortality have widened in recent years. The gap in healthy life expectancy at birth is about 19 years for both males and females.
    • Spending constraints between 2010 and 2014 were associated with an estimated 45,000 more deaths than expected: those aged >60 and in care homes accounted for the majority
    • There has been a systematic attack on the social safety net. Services have been cut disproportionately in more deprived areas with a clear North South divide, and there are higher rates of poverty in the Devolved Administrations who have limited powers to mitigate the impact of poverty. Child poverty has increased to over 4 million children
  • The COVID19 pandemic is having major impacts on health, through direct and indirect effects, summarised the in diagram below

Source: Douglas et all, BMJ April 2020

  • The pandemic strategies are not clear across the UK and do not adequately recognise the unequal direct and indirect impacts.
    • The epidemic is at different stages in different communities and has caused more deaths in dense urban and more deprived areas.
    • It can be seen as multiple outbreaks. These are affecting the most vulnerable people inequitably, such as those in institutional settings, prisons and migrant detention facilities, homes with multiple occupancy, and households that are overcrowded or contain multiple generations.
    • A policy of managing the virus rather than aiming for suppression, may result in repeated surges, local outbreaks and lockdowns which could exacerbate the impact on health and further widen health inequities
    • The centralisation of data and decision-making has meant that approaches cannot be matched to the needs that only the regional and local level will know well enough and in real time
  • There is a consensus that the COVID19 pandemic has a major potential to widen health inequities,
    • As can be seen from the diagram above, the health impacts are likely to have differential effects on different groups of people, in particular:
      • Those most vulnerable to the infection: such as older people, BAME people, those living in enclosed settings
      • Those on low incomes or living with financial insecurity
      • Vulnerable families: for example, those at risk of domestic violence, those who are poorly housed, children at risk of abuse or neglect
      • Those at risk of social isolation
      • Vulnerable groups: for example, the homeless, people with disabilities, undocumented migrants
      • High vulnerability and institutional settings where outbreaks can occur rapidly.
      • This pandemic has made us focus on older people, and the young are paying a high price for protecting the old. Impacts on the young will have more long-lasting impacts on health inequities
      • Inadequate public health expenditure and ‘shrinking the state’ disproportionately affect poorer people including our BAME communities. More ‘austerity’ to ‘pay for’ the pandemic is not an option as austerity widens the health inequalities that lead to disproportionate mortality due to direct and indirect impacts of COIVD19
  • Deprivation: people living in more deprived areas are more likely to die from COVID19
    •  ONS analyses have shown that the age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas of England was 55.1 deaths per 100,000 population compared with 25.3 deaths per 100,000 population in the least deprived areas. In Wales, the most deprived areas had a mortality rate for deaths involving COVID-19 of 44.6 deaths per 100,000 population, almost twice as high as the least deprived area of 23.2 deaths per 100,000 population.
    • The Kings College Symptoms tracker found that COVID-19 prevalence and severity became rapidly distributed across the UK within a month of the WHO declaration of the pandemic, with significant evidence of urban hot-spots, which tend to be more deprived areas.
    • The openSAFELY cohort study used national primary care electronic health record data linked to in-hospital COVID-19 death data, which is the largest cohort study in the world, examining 17 million primary care records. This showed a gradient from least deprived to most deprived, adjusted for age, sex and risk factors, so that people living in the most deprived quintile have a risk of 1.75 that of people in the least deprived

Hazard ratio for in hospital COVID19 death (adjusted for age/sex/risk factors

IMD quintile of deprivation
  • Unequal impacts
    • People living in more deprived areas are more likely to be exposed to COVID19:
      • Population density and overcrowding: urban poverty
      • Occupational exposure: more likely to be key workers and less likely to be able to work from home
      • Vulnerable groups e.g. homeless, refugees and asylum seekers, substance misusers
    • People living in more deprived areas are more likely to die when they get sick with COVID19:
      • They develop multiple co-morbidities at younger age (people in the most deprived areas get sick 10 years younger than the most affluent)
      • Equity of access to quality health and social care mitigates this, but has become eroded as austerity has hit services in the poorest areas most
      • They are more likely to also be from BAME groups
  • We have evidence on what works to reduce inequities in health
    • We know what causes inequities in health outcomes. The WHO Commission on Social Determinants of Health in states that inequities are caused by the conditions in which we are born, grown, work and live. There is now a large body of evidence from expert reports on health inequalities from academic as well as government sponsored reviews (Black and Acheson) for the past 40 years.
    • We know what works to tackle inequities in health: this can be usefully summarised by Sir Michael Marmot’s six policy areas for action:
      • Give every child the best start in life
      • Enable all children, young people and adults to maximise their capabilities and have control over their lives
      • Create fair employment and good work for all
      • Ensure healthy standard of living for all
      • Create and develop healthy and sustainable places and communities
      • Strengthen the role and impact of ill-health prevention
    • No strategy: the UK government has not prioritised health inequalities, and England has had no health inequalities strategy since 2010, although devolved nations have policies within the constraints of their powers.
    • But we have assets: We have seen how individuals and communities are resilient, and this has been amply demonstrated in their amazing response to this public health crisis. We should be following Prof Sir Michael Marmot’s advice: “Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

Conclusions:

  1. There are already major inequities in health outcomes in the UK, and these have been getting worse
  2. COIVD19 is disproportionately killing the less affluent and those in vulnerable groups
  3. There is a very high risk that the indirect impact of COVID19 will worsen health inequities through well-known mechanisms.
    • Greater vulnerabilities: for example, the higher prevalence of co-morbidities and complex multi-morbidities, ethnicity, disability
    • Higher exposure: for example, through occupations, overcrowding, enclosed settings, multi-occupancy households
    • Less access to resources to protect against economic and financial impacts
    • Less access to quality public services

Actions

  • Commit to a long-term inequalities’ strategy with a multi-faceted approach building on previous Labour success 1997-2010. This should be even more ambitious, to tackle the commercial/ structural determinants of health, and to create healthy communities and places: it should reduce reliance on less effective individual behaviour change strategies, and include the intersectionality of disadvantage
  • Decentralise data and decision-making for COVID19 to better allow resources and control measures to be matched to need
  • Focus on elimination of transmission of COVID19 high risk settings, for example social care and health service facilities, prisons and migrant detention facilities, homes with multiple occupancy, and overcrowded or intergenerational households
  • Redistribute wealth: Maintain social protection measures as long as required and then in the longer term: implement Universal Basic Income and a Green New Deal with an economy based on need not profit. Ensure proportionate universal allocation of resources o Prioritise children: ensure safeguarding/ tackle domestic violence/ prevent unwanted pregnancies/ action to ensure healthy pregnancy outcomes/ push for childhood vaccinations programs to continue/ get children back to school as safely as possible
  • The NHS and social care should be always provided by need and not ability to pay: the state is a protective factor against unequal exposures to health determinants, as a provider, enabler and employer
  • Build and nurture the grassroots movements that have blossomed during the pandemic, and establish community oriented primary care to empower communities to create healthy communities

Sources

  • Watkins J, Wulaningsih W, Da Zhou C, et al Effects of health and social care spending constraints on mortality in England: a time trend analysis BMJ Open 2017;7:e017722. doi: 10.1136/bmjopen-2017-017722
  • https://bmjopen.bmj.eom/content/7/11/e017722

Posted by Brian Fisher on behalf of the Policy Team.

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