Category Archives: Equality

Mean societies produce mean people

Babies haven’t changed much for millennia. Give or take a few enzymes this perfectly designed little bundle of desires and interests has not needed to evolve much. Of all primates, the human is the most immature at birth, after which brain growth accelerates and is ‘wired’ according to the kinds of experience the infant has. Provided there are a few familiar and affectionate people there to care continuously for him or her, baby will be fine. If not, evolution has taken care of that too. You live in a cruel world and treat him roughly? He will develop into a compulsively self-reliant and ruthless individual with little concern for others. Mean societies produce mean people. Through attentive care in the early years we may hope to produce thoughtful, curious and confident young people but our social arrangements are essentially hostile and competitive. Having a baby is regarded as an expensive undertaking rather than as a contribution to the future of society.

Encouraged by successive governments our world is geared to markets. “It’s the economy, stupid” means you can’t do anything without considering the immediate cost. The more this idea takes hold the stupider we become. The current government’s dedication to continuous welfare cuts hits children disproportionately. Neoliberalism is the enemy of children.

Evolutionary imperatives

This is not the environment in which humans evolved. An infant in a hunter-gatherer band – the way we all lived for 99% of our time on the planet – would have spent many hours being held, and not only by the mother. “Infants with several attachment figures grow up better able to integrate multiple mental perspectives”. We are programmed from the start to seek out third positions, to acquire the “capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting on ourselves whilst being ourselves.”

Systematic comparisons between sedentary foraging and farming people living now in neighbouring parts of the Congo basin show how much more egalitarian the foragers are. Men and women see themselves as equal. They hold and converse with their tiny children more intensively, they let the baby decide when to wean and teach them to share from an early age. Violence is rare, though teasing is common. Such children are more socialised than in the west and at the same time protected from catastrophe in the event of the mother’s death. Amongst the farmers, in contrast, “corporal punishment is not an uncommon response for young children who do not listen to or respect their parents or older siblings”.

In the modern world little public money is available for perinatal services, parental leave, for quality child care and universal education, affordable and secure homes, healthy food, subsidised transport and energy, sports fields, swimming pools, libraries, parks and playgrounds that make rearing children and adolescents more manageable and more successful. Tax, like children, is seen as a ‘burden’. So governments of all parties sign up to reducing it, yet still find money for bank bailouts and unsustainable wars. Whether local or national, tax should be a contribution to the common good, an instrument of social justice. It is collected from citizens, for citizens. In the current climate this equation is neither acknowledged nor understood. Yet something has been understood that was not clear before. There is a greater recognition that early intervention is a good idea: “the brain can be sculpted by experience”; the sooner the better.

Start at the beginning

When a woman becomes pregnant her physical and mental states impact on her child. From conception onwards the health and resilience of children – and the adults they will become – is compromised by stress, diet, maternal weight, drugs, genes and insecurity in their parents. Besides the impact on the mother herself, anxiety and depression during pregnancy and after it have significant long term effects on the child’s physical and mental health – particularly on boys – generating huge social costs. Pregnancy is a dangerous time for some women. The most socially deprived mothers are more likely to have very premature births or perinatal death. Low birthweight leads to poor outcomes; early intervention can reduce that.

Elegant research shows how already by a few months old babies are engaged in triadic relationships; they are affected by tensions between the adults caring for them. When caregivers are uncooperative infants may be “enlisted to serve the parents’ problematic relationship rather than to develop their own social competence”. Children will more likely thrive if caregivers – parents and grandparents, childminders, daycare and children’s centre staff, nursery teachers – get on with one another, like a good team. “Communication between parents and care providers is crucial to the quality of care.”

The routine availability and presence of health visitors and other staff supporting new parents and of Sure Start centres for children and families create the conditions for reliable care of children. In a context of skilled early years provision, infants whose parents are paid to spend time with them in the early months are less likely to die. “A ten week extension in paid leave is predicted to decrease post neonatal mortality rates by 4.1%”. This remarkable finding represents just the tip of an iceberg of developmental damage and pathology, modifiable by intensive early support for families.

Better training and pay for early years staff improves outcomes and reduces turnover. UK needs to learn from continental Europe the tradition of pedagogic professions: proper pay, status and training for the job, particularly when the families most in need are hard to engage. Looking after small children is demanding and stressful, requiring continuous professional development such as reflective discussion groups in which colleagues both support and learn from each other. Work with young families is a professional skill.

Inequality undermines trust

A collaborative partnership between caregivers does not in itself cost money, but is undermined by social disintegration, the most poisonous source of which is rising inequality. In Britain this has reached levels not seen since the 1920s. The much maligned 1970s was actually the most egalitarian in our history. Consider this: one index of social health is the number of boys born in comparison to girls. Because the male fetus is more vulnerable to maternal stress, women produce fewer boys when times are hard. (For example there is a fall in the ratio of boys to girls a few months after disasters such as massive floods or earthquakes, or the terrorist attack on 9/11). In England and Wales the highest ratio of boys to girls occurred in 1975. In terms of contented mothers it was the best of times.

Inequality creates stress in parents who can’t keep up, and anxiety in the better off who fear sliding down. No one is comfortable on a steep slope. It makes all of us less trusting and more averse to communal commitments, such as respecting our neighbours and paying tax. Infant mortality, mental illness, drug abuse, dropping out of education, rates of imprisonment, obesity, teenage births and violence are all higher in unequal countries like ours.

Though often disappointed, our ancient baby is born to expect some kind – a rather conservative kind – of socialism. What will today’s infants be talking about in 2050? If they know any history they will regret lost opportunities; our collective loss of vision that led to wasted generations. The success of the post war consensus was due in part to the fact that it lasted longer than one or two parliamentary terms, so that children could grow up, get educated and housed, find partners, get work and free healthcare without overwhelming instability or despair. The needs of a baby born today are precisely what they were for one born in the 1950s, or 50,000 years ago. New knowledge of infant development is catching up with evolved wisdom, yet we continue to ignore both, and build bigger obstacles to secure attachments.

 

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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The case for a new Beveridge Report

One of the last Labour Government’s real successes was to preside over an increase in life expectancy. In addition, the gap in life expectancy between the rich and poor decreased. Fast forward nearly 8 years, to March 2018 the Office for National Statistics published data showing that under Tory austerity the gap in life expectancy had widened. For women, the gap is the largest since the 1920s.

There is overwhelming evidence that these inequalities are not inevitable. They are socially reproduced. They can be changed. And that should give us all hope. But it needs political will to tackle them, not the soundbites of this Government.

In 2015, the International Monetary Fund stated that ‘widening income inequalities is the most defining challenge of our time’. Forty years ago, 5% of income in the UK went to the highest 1% of earners. Today it is 15%. According to the latest Sunday Times Rich List, the richest 1000 people in our society saw their wealth increase by 16% in the last year alone. This trend of increasing income inequalities has occurred in most high income countries, but some less than others.

Like Nobel economist Joseph Stiglitz’s, the IMF’s analysis showed that inequalities are a drag on growth and can also make growth more volatile. It showed that raising the income share of the poorest 20% of the population increases growth by as much as 0.38% over five years. In contrast, increasing the income share of the richest 20% by 1% decreases it by 0.08%.

The Organisation of Economic Co-operation and Development has also rejected ‘trickle down’ economics, so popular with Margaret Thatcher and her supporters, as the means of spreading income from the rich to the poor.

In spite of promises to tackle these ‘burning injustices’, according to the Equality Trust, Britain’s top bosses are paid, on average, 165 times more than a nurse, 140 times more than a teacher and 312 times more than a care worker. Indeed it would take a typical UK worker 160 years to rake in the average annual amount handed to a FTSE 100 boss.

The recent Equalities and Human Rights Commission report has revealed that the poorest tenth of households will on average lose about 10% of their income by 2022 – equivalent to £1 in every £8 of net income. This reflects other distributional analyses for example from the Institute of Fiscal Studies.

Reducing the gap between rich and poor is not just good for the economy. As evidence from The Spirit Level shows, life expectancy increases, as well as educational attainment, social mobility, trust and more. Fairer more equal societies benefit everyone.

In acknowledging the income inequalities that exist in the UK and the harm that this is doing to society as a whole, the question is what drives them and how to tackle them.

As Labour committed to in last year’s manifesto, we need changes to economic policy to address the unfair tax burden and poverty pay. But we also need to radically transform our social security system so that, for example, 8 million people currently in low paid jobs are not left living in poverty while they wait for pay improvements, and neither are their children. And if you become sick or disabled you should not be twice as likely to live in poverty as non-disabled people, as 4 million disabled people are now. Similarly, the state pension age for men and women shouldn’t be quietly pushed back, leaving increasingly frail, elderly people unable to work, subjecting them to live in poverty.

The 1942 Beveridge Report was the basis for a new welfare state set up after the Second World War, including the establishment of the NHS in 1948 and the expansion of social security. It was heralded as a revolutionary system that would provide ‘income security’ for its citizens ‘as part of a comprehensive policy of social progress’.

Since 2010, we have seen social security spending cut by nearly £34bn, with another £12bn planned by 2022. Spending on the NHS is barely keeping pace with inflation, and is falling behind countries like Germany, France, the Netherlands, Denmark and Austria.

We need a new Beveridge report for the 21st Century, defining a new social contract with the British people, addressing the poverty, inequalities and indignity millions of people, young and old, are enduring; bringing hope to a new generation as it did 70 years ago.

Of course these reforms need to be coupled with reforms to the current dysfunctional and increasingly precarious labour market as part of a coherent and comprehensive industrial strategy. Labour’s plans for a national education service that is not just about preparing you for work but is enabling you to get the most out of life, are also essential to tackle the structural issues that drive these income inequalities.

In addition to inequalities in income, inequalities in wealth, with land and property being the largest real asset, also need addressing. In 2002 it was estimated that 69% of the land in the UK was owned by 0.6% of the population. In the six years to 2011 the number of landholdings reduced by 10% but the size of these holdings had increased by 12%. So even fewer people own even more land.

Many in housing policy emphasise that if we’re to solve the housing crisis in addition to building more homes, we need to tackle the cost and availability of land and address the volatility in the market. With average house prices in the UK in 2017 at over £226,000 (over £496,000 in London), the Nationwide Building Society has estimated that it would take 8 to 10 years for people on average incomes to save the 20% deposit needed to buy a house and even longer for someone on a low income. Which means wealth inequalities are increasing even more.

And finally there’s inequalities in power. This is often the neglected inequality but is central to who we are as human beings. Power is complex. It is about having influence, control, even authority. We usually think of this as associated with having money or ‘corporate power’. But it is also about position and status. In who makes decisions and how. Whether corporate or other unaccountable, ruling elites, the dangers are clear. Elites exclude and marginalise, enabling prejudice and discrimination to thrive, and trust in others, in difference to suffer as a consequence.

Inequalities are not inevitable but to tackle them in all their forms takes commitment, it takes courage and it takes leadership.

First published on Debbie’s website 

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It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.

Smoking

Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

Obesity and malnutrition

I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

NHS funding

Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

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1) Holistic care:

Mental health and social prescribing services are doing their best in our practice area but are massively under resourced. Don’t forget the critical importance of valuing continuity and teamwork in the primary care team – really important for safeguarding, morale and retention of staff. See Watton in BMJ, especially around Health Visitors and District Nurses within practice teams. Same points apply re social prescribing / CSW / Health Trainers

Due to the clear correlations between deprivation, psychosocial problems and physical health, it is a false economy not to invest in mental health and social prescribing as ultimately patients fall back on more expensive NHS services. Many of our patients are illiterate or have poor health literacy and so patients often fall through the gaps of traditional appointment systems with letters and phoning back to make appointments even if they are in the correct age range (which many are not as they are too young or housebound). Many of our patients are struggling due to being victims of emotional, physical or sexual violence: their anxiety can be displayed as anger or addiction.

Improving Access to Psychological Therapies

It is fantastic to have IAPT counsellors in the building (as you know many patients do not attend other sites) but due to the constraints they are working under often our patients living in the most deprived area of Sheffield do not fit the criteria as they can be chaotic or ‘not ready’ for the emotional challenge of counselling.  I wonder if a more flexible type of approach could be taken, many of our patients need to build up trust with professionals over serial encounters before being able to engage – the IAPT triage service doesn’t allow for this, sadly. 

Groups or lectures are on offer around the city but our patients struggle on many levels to attend these due to poor self esteem, confidence and practical issues such as buses, school pick up and travel costs.

I also wonder if a ‘trauma therapy’ approach may be more useful for our patients as I heard about this from another Deep End GP in Glasgow.

In summary there are great counsellors and charities working in our area doing outstanding work beyond their resources but it is insufficient due to the massive need on the our, patients fall through the cracks and this perpetuates poor health and greater pressures on NHS services. Investing more to support mental health services and social prescribing feels right on a moral and financial level to reduce inequalities.

 2) Families and Children:

The links between early childhood experience and brain development has long been known and the field of epigenetics is emerging.

The local family planning clinic has been closed. We predict that unwanted pregnancies will go up in our area. We think investing in sexual health and contraception services, educating girls and women would help inequalities. Early years are crucial yet we have had the team dismantled – the overstretched health visitors are no longer in our practice. When I was a trainee in 2002 the health visitors knew all the families and who to worry about, came to all the practice meetings and we also debriefed over the kettle (a very underestimated source of support and sharing ideas and information!).  Not having the health visitors in our practice feels like a serious threat to safeguarding.

My suggestion would be to get the health visitors and district nurses back in the practices and integrated in the teams – we need more of them too! We need more support to provide contraception, sexual health services and parenting sessions.

3) Multimorbidity & Complexity: 

Again the links between deprivation and complex medical problems and multi morbidity at a young age have been proved and we need help to support our patients with these.

There has been a fantastic collaboration at The Whitehouse for many years between Prof Heller the diabetologist and the primary care team; once a quarter Prof Heller and his specialist nurses come for lunch and a cuppa at the practice and the Multidisciplinary team present our patients with Diabetes for a case discussion. These are complex patients who often won’t attend hospital outpatients. This opportunity of case discussion is so valuable on many levels. It builds personal relationships between primary and secondary care which allow a 2 way flow of information, education and morale essential to providing high quality care to patients. Our patients are not only suffering serious physical problems but the case discussion also allows us to acknowledge their complex lives and histories.

We have also been lucky enough to be part of a pilot with joint clinics between a Paediatric Registrar and GP trainee: this has been shown to reduce out-patient appointments and again develops supportive educational relationships.

We particularly need help with patients who have persistent pain and addiction to prescription drugs – experienced physiotherapists who are aware of issues surrounding deprivation would be a real asset to decreasing inequalities, as this could improve people’s chances of getting back into work and improve quality of life.

More educational cased based discussions between primary and secondary care specialists are fantastic educational opportunities and are invaluable to give the best patient care: Could we have more specialists coming to the practice like Prof Heller? It must be cheaper than running an out patient clinic and studies show that it does reduce referral rates and improve the quality of referrals.

4) Lifestyle: Smoking and getting more active.

We would like our stop smoking service back in the practice! Patients are reluctant to go to the ‘pharmacy’ for this, even though it is relatively close by.

We have recently been in discussion with SIV to see if our patients can have more support in our practice building to get more active and build confidence to going to other venues with someone they trust. The barriers to exercise are complex: one of my patients has flash backs to being raped by her brother and father when her heart rate goes up; another after being raped wanted to make herself obese so no-one would ever fancy her again.  Our patients need kind, broad shouldered, flexible and good humoured health trainers to overcome these barriers.

Health trainers working in house with physios would be really helpful to reduce inequalities.

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Introduction

This is the first in a set of two blogs attempts to describe the story of health inequalities in a town and recent history, why this remains important, what a strategy might look like and how it might be framed.

Blog 1 considers the story in Sheffield to date, framing, context and language, the impact of systematic strategy.

Blog 2 will cover general approach to intervention and specific actions or interventions we should implement.

Blog 3 will cover the perspectives of two jobbing GPs working at the sharp end of this

Blog 4 will cover some thoughts on where next

I’m sorry it’s a bit long and complex ………

  1. The story in Sheffield to date

How do we do?

Inequalities in health outcomes in Sheffield are well documented: there is a 20 – 25 year gap in healthy life expectancy between best and worst along the normal dividing lines of deprivation,  mental health, learning disability, ethnicity, etc.  The Marmot indicators, which outline this in more detail, can be found here.  They were replaced in 2016 by the PHE Wider Determinants Tool.  This includes a “Marmot Indicators” domain.  This paper will not discuss these further for brevity.

The current strategy for Sheffield

Sheffield has a Sheffield Health Inequalities Plan agreed in 2014.  The plan was lifted straight from the Joint Health & Wellbeing Strategy (JHWBS) and is made up of all the recommendations in the JHWBS that refer to health inequalities.  The JHWBS itself arose from the JSNA.  It wasn’t something separate and different: putting health inequalities into a separate plan was supposed to make us all focus explicitly on health inequalities.

In retrospect, most seem of the view that it didn’t achieve that objective; something similar could be said of the JHWBS.  It’s a little old now, and all acknowledge there is a need to revise or rewrite it.  We all know that health inequalities as one of its most important priorities.  We mostly accept there are no simple easy solutions.

The Sheffield HWBB has held two recent discussions, in December 2015 and June 2016.  The December 2015 meeting focussed on quantifying the challenge, while the June 2016 meeting focused on agreeing a refreshed strategy; building on the 2014 plan.  In June 2016 there were five areas of focus, reflecting a need for interventions with a short and long term return:

  • Continued commitment to an asset based community development based approach to health and wellbeing
  • Continued investment in and commitment to primary care and within this General Practice services, especially in the most disadvantaged parts of the city
  • Continued commitment to the principle of implementing effort and change where greatest need is identified
  • Refocused effort on the link between employment and health
  • When looking at “healthy lifestyles” focus on the environment and make the healthy choice the easiest and default choice.

Clearly these  five areas highlighted were not the only answer to the difficult issue of health inequalities; rather, these were the areas where the Board agreed to focus first.

The Board also requested that emphasis be given to the concept of moving from an equal offer to a differential offer with a view to achieving an equitable outcome.  This implies a tailored response to greater need.  Finally it’s important to recognise the set of things that can be changed at Sheffield level whilst recognising the continuing need for on-going pressure for national change.

It’s not just about deprived geographical communities

A focus on both geography and specific population groups is needed.  The geography issue is broadly a point about socioeconomic deprivation, but it is important to note that this is not just about “the poor” but other excluded groups as well.  Other important groups include homeless individuals, prisoners, sex workers and people with substance use disorders, to name just a few.  Of course, these populations can overlap: for example, substance use disorder is common in other socially excluded groups.  There are many other groups with substantially poorer outcomes than the population average.

The Board also identified that specific population groups require additional focus including, for example: children and young people, BME groups, those with learning and physical disabilities and those experiencing mental health problems.  This was a specific issue around vulnerable groups of people, including but not limited to the protected groups identified in equality legislation.  The advantage of a double and layered approach is that it allows for multiple inequalities to be handled at the same time.

There is a wider context

The three themes of Due North (Poverty and economic inequality; Healthy development in early childhood; and Share power over resources and increase public influence over decisions) are still pertinent.  The Due North analysis is essentially a socio-economic one which builds on this to make the case that economic inequity leads to alienation.  Due North argued for the need to  strengthen the role of the public sector and tried to address the complexity in this by talking to three different agendas (regionalism and government structures, greater transparency of decision making at a local level and collective forms of ownership).  Arguably Due North was weak on the role of the community and voluntary sector, especially grass roots community organisations.

There is a much broader context across the city also.  The single biggest factor driving the health gap in the UK is the wealth gapThere are also substantial work streams around issues of direct relevance to health inequalities: work on inclusive growth, the Fairness Commission, and SCC’s/City work on poverty, to name just a few.  Relevant strategies in other policy domains are in place, but these may be partial and disconnected – financial security, community stability, community coherence – all need to be pulling together.

  1. Why it remains important
  • Injustice in itself;
  • Social cohesion – Marmot suggests that in societies with substantial inequality the considerable gap between the top 1% of income earners and the rest of society threatens social cohesion;
  • Important factor in the slowing down of improvements in Life Expectancy and Healthy Life Expectancy;
  • HWBB (and the partners involved) has a legal requirement to address inequality in access and outcomes – See here.
  • Not addressing demand will lead to costs to the state that are unfunded and storing up problems for the future. This can be thought of as addressing diabetes vs obesity vs the determinants of obesity;
  • This is NOT a side issue, it is a population issue. Inequalities are bad for ALL of us – we’re ALL worse off as a consequence.  It’s not just about the most deprived.  Inequality is a societal issue: when expressed in terms of the economy, inequality is a drag on total societal production.  The same may well apply to wellbeing, such that inequality in wellbeing is a drag on total societal health and wellbeing.  Societal health and wellbeing is then a driver of demand for services;
  • It is not only a public funding issue but public funding is an important social protection and source of investment in things the market won’t provide.
  • From an NHS perspective, inequity in morbidity (and multi morbidity) is driving demand, expressed in terms of consequences for the health care system, with a 15 year differential between the most and least deprived in the onset of multi morbidity. We can document this in Sheffield and it is a driver of demand for public services. I’d encourage readers to consider my take on the  the most important charts in health care, particularly chart 2, 3 & 4. This is where the demand in your health and social care system is coming from. I’ve blogged on that. A lot. And won’t repeat all that here
  1. Why has there been limited to no progress?

Nobody underestimates the difficulty of moving some of these debates forward, because there are no easy or simple answers.  Measurement is easy and talk is easy, but concrete progress is difficult.  Reasons for this limited progress include:

  • There isn’t a burning platform for the issue that everyone aligns around – the money. Whilst there’s  a platform around social justice, amongst other things, this is not connected to the demand and resource implications of inequalities; Addressing health inequalities is not seen as mission critical to the business.  There isn’t a “business case” clearly written and articulated on it.  However, until we sort out wealth inequality there is limited/to no point talking about economic productivity;
  • Differential resourcing is very difficult, politically and operationally;
  • The wider context is exceptionally challenging. We are facing the most challenging outlook for public services since the 1970s.  Pre-Brexit, the signals were that austerity would continue into the 2020s; post-Brexit, no economics textbook in the world says that a decade of uncertainty is a good thing.  This has clear implications for public services that are incredibly dependent on the economic cycle.  Austerity is certainly making inequalities worse not better, through direct impacts on individuals and the indirect result of cutting the social security safety net.  It has been well documented that the impact of austerity is worse in areas that are more deprived ([1],,[2][3]).There is also a layering effect of multiple cuts on families.  The 40% Local Government cut will and is directly affecting the things that determine health of individuals and communities (such as the closure of Surestart Centres).  We can’t keep cutting and expect nothing to happen.  It would appear that both quality and length of life is deteriorating as we get deeper into the impact of austerity;
  • Beyond austerity, the resource allocation formula itself has created inequality;
  • Governance: the current challenge needs stable long term government.  We have a minority government: history (1970s) suggests it will last, but that the government will be thinking in days and weeks, not months, years or decades.  There is a need for a fundamental realignment of systems but in a minority government, the overriding mind set will be “is it contentious?”  Realigning priorities is contentious and thus likely to not happen.  At the local level, governance is messy, with differential levels of devolution, financial challenges and limited stability.  Grenfell Tower is an obvious and emblematic tragedy and profound in governance terms.  It has challenged all of us as we have created an “efficient” delivery system through outsourcing leading to fragmentation where nobody is in control, and leaders have no line of sight and no real control.
  1. Language and framing of health inequalities. It matters

There is value in being clear about how we understand and talk about the issue that is health inequalities, including the words and framework we use.

The issue could be Framed around the following domains (not necessarily in order of importance before anyone gives me grief):

  • Our health behaviours and lifestyles
  • Wider determinants of health
  • Communities and health
  • An integrated health and care system

The Marmot areas of recommended policy focus remain the benchmark:

  • 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 a healthy standard of living for all;
  • Create and develop healthy and sustainable places and communities;
  • Strengthen the role and impact of ill health prevention.

It may also be framed around life course (starting well, living well, ageing well) and in terms of services for people and places where people live. 

There is also merit in bringing together the various strands around equality, poverty, inequality and similar as many of them cover similar space

What words do we use matter

The language of “health inequalities” might benefit from simplification: Consider the impact of “health inequalities” vs “poorer health and shorter lives”.  There is a need for language that communities really engage with.  The Robert Wood Johnson Foundation have done some interesting work in this space, as have the Frameworks Institute, specifically here.  In discussion with residents, there will likely be a focus on their priorities relating to the here and now.  Getting public focus on health inequalities might take some doing.

What framework do we use?  Julia Lynch makes the case of the danger of “medicalising” or individualising heath inequalities:

ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.  Medicalizing inequality is appealing to many, more appealing than tackling income and wage inequality head-on.  But it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve.  Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities”.

Similarly Marmot points out that evidence on “tackling” health inequalities tends to be focused on the biomedical model paradigm and evidential thinking.  Marmot recently noted that “downstream” interventions have been covered, for the most part, in the scientific literature.  There has been much less focus on structural interventions.

If one went purely by the numbers of papers published, one would put effort into pharmacological treatment and would ignore housing; emphasise case management and ignore poverty”.

We need to be clear that “Health” does not mean the same thing as “the NHS”.  We should define the differences between “Health”, “NHS” and “Social Care” vs “Health” and “Wellbeing”.  Using the narrative being promoted by Prof Burns on salutogenesis (what causes good health) vs pathogenesis (what causes ill health) could help.

Determinants are not inequalities and vice versa.  The term “determinants” is one way of expressing the risks to health and wellbeing.  They are upstream risks, assets or protective factors.  Both upstream and downstream factors matter, but we should start from the position that upstream factors matter more.  Inequity is the differential distribution of these factors.

Health inequality is therefore about:

  1. The unequal distribution of clinical and lifestyle risk factors (a small part of which is about the NHS)
  2. The unequal distribution of social and environmental risk factors (the determinants)
  3. The determinants of the determinants (power, concentration of wealth, dominant economic model etc.)

Health inequalities are not a “health” thing, or indeed a “public health” thing.  The consequences of “health inequalities” are social and specific to the NHS only in terms of demand.  Some argue in this context that the Department of Health & Social Care is the wrong sponsor agency, as it is responsible for the consequences of failure rather than the solutions.  There is also a danger that DHSC sponsorship will tend to lead to health service design solution thinking first.

The causes are largely upstream of the NHS.  There are local, regional and national aspects to the solutions, especially in terms of skilled advocacy and challenging conversations with other parts of government, and the economic, social and political ideologies that make the inequitable distribution more likely: the determinants of the determinants.

  1. The impact of a deliberate strategy: is it worth the effort?

Yes.

From a number of viewpoints. If you don’t care about social justice and important stuff like this, and only care about demand for services and money – I’d encourage you to very carefully consider the last two bullet points in section 2 above. This directly links inequality to demand, and illustrates why it’s not just a soft fluffy social policy issue.

Barr highlighted the positive impact of a deliberate strategy at national level, considering geographical health inequalities measured as the relative and absolute differences in male and female life expectancy at birth between the most deprived local authorities in England and the rest of the country.

The analysis suggests that prior to the introduction of the English Health Inequalities Strategy, geographical differences in life expectancy and health were widening.  During the implementation of the strategy, these trends were reversed but since this program ended there is evidence to suggest the improvement is being undone.

The period of the strategy encompassed a time (up to 2008) of increased public spending, economic growth and stability, relatively low unemployment, and increased investment in both healthcare and programs that addressed the wider determinants of health.

There was not always a clear distinction between policies that were part of the health inequalities strategy and policies that would have happened anyway in the absence of the strategy.  However, this period of increased social investment across the whole of government, targeted at disadvantaged areas and groups, was associated with a decline in health inequalities and geographical differences in life expectancy.

The end of the strategy and the start of the austerity program which reversed many of the key policies occurred at the same time, and therefore the effects of the program ending and austerity starting cannot be separated out.  However, there is clearly a stark contrast between a time when investment in policies which addressed the wider determinants of health resulted in a reduction in geographical differences in life expectancy and health, and the current policy environment which may be reversing those trends.

The reductions in the gap between best and worst were circa 1 year, which is hugely significant given the population nature of life expectancy. Think of the number of life years involved in such a change in life expectancy, then think about the morbidity – and thus lost productivity economically speaking and heath / social care use that preceeds  death.

References.

1 See here for evidence in strong gradient  in correlation between LA cuts and deprivation local authority level analysis from CRESR report (those with most need in population worst affected)

2 See here for impact of welfare reform split in other ways from Equality and Human Rights Commission report

3 See also Liverpool John Moores – Welfare reform, cumulative impact analysis 2017

First published on the Sheffield DPH blog

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How do early circumstances influence us later in life? Previous studies have found that socio-economic factors in early life can continue to have persistent impacts throughout one’s life and, coupled with circumstances in adulthood, jointly contribute to later health. Understanding these influences can therefore be beneficial to policies aiming to reduce health inequalities. This is why studies using longitudinal data, and especially those sampling a specific cohort, are particularly useful in disentangling the relationship between early life and later health.

The 1958 British National Child Development Study (NCDS) makes available rich data, ideal for this line of study. The NCDS has followed over 17,000 individuals born in 1958 for 50 years, providing information across different domains (e.g. physical, social, and health) and at different stages in life. Yet socio-economic circumstances are difficult to measure in practice, because they are multi-dimensional and sometimes unobserved. So, how can we represent complex pathways by realistic statistical models?

Our research proposes a structural model that connects the socio-economic circumstances in childhood, partnership history in adulthood, and health in midlife (Figure 1). Around 50% of individuals in our British cohort (currently in their 60s) grew up in families with unfavourable conditions in at least one of the four dimensions of socio-economic circumstances that were identified in the early phases of the study.

Effects of childhood circumstances

Figure 1: Path diagram showing the effects of childhood socio-economic circumstances (SECs) on later health

Having performed the analysis, we are able to formulate four sets of conclusions.

  1. Do childhood socio-economic circumstances directly influence midlife health?

We find that the estimated effects of father’s social class, financial difficulty, and material hardship in childhood on midlife health to be significant and similar in magnitude, before and after controlling for partnership experiences. This suggests the influence of these factors during one’s childhood are long-lasting and persistent, and that those with unfavourable conditions in these aspects are significantly more likely to be in poor health at age 50 (Figure 2).

Figure 2: Predicted population-average probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

 probabilities of being in poor health state at age 50 for each level of childhood socio-economic circumstances

Note: Marginal probabilities are computed keeping all the other covariates fixed at their observed values for each individual. Individual-specific random effects are simulated from the estimated distribution.
  1. Do partnership experiences influence midlife health?

We find that individuals who have formed their first partnership later in life tend to have a lower risk when it comes to developing health issues at age 50. Also, among those who have started the first partnership at the same time, cohort members who have spent longer time single before the age of 50 have a higher chance to be in poor health in midlife.

  1. Are there any indirect effects of childhood socio-economic circumstances on midlife health?

The results suggest that an unstable family structure in childhood pushes up the likelihood of poor midlife health but the effect is not directly transmitted: rather, only through an indirect path via one’s own partnership experiences. We find that unstable family structure significantly increases the likelihood of the early formation of first union and that of subsequent dissolutions.

Back to the health submodel, cohort members who formed the first partnership early are significantly more likely to be in poor health in midlife, and those with shorter partnership episodes, i.e. those who spent a higher percentage of time single, have a relatively higher risk to develop health issues at age 50. The evidence confirms the hypothesis that the influence of childhood socio-economic circumstances on midlife health is partially mediated by partnership experiences.

  1. Do different partnership experiences share common influences not captured by observed characteristics?

Our analyses find that such shared influences do exist. Certain individuals who form their first relationship early tend to be less likely to suffer a relationship breakdown. In the future phases of the study, we will investigate the individual-specific characteristics relevant to this correlation – such as whether those with a mutual interest in being in a quality relationship tend to maintain the union, lowering the risk of separation.

First published on the British Politics and Policy blog

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‘If livin’ were a thing that money could buy / The rich would live and the poor would die.’  It is, and these lines, from a spiritual temporarily made famous in the 1960s by Joan Baez, remain the best succinct description of the origins of health inequalities.

Occasionally, that reality thrusts itself into the consciousness of the high-income world, as in the case of Hurricane Katrina and the Grenfell Tower disaster.  In the case of Katrina, when the hurricane hit and the levees broke (after years of governmental neglect), evacuation plans presumed that everyone had access to an automobile.  Those who could afford to do so packed up the car and drove to higher ground.  Others, overwhelmingly poor and African-American, were left to fend for themselves as refugees in their own country.  The disposability of certain populations, from the point of view of the powerful, was similarly evident in the case of the Grenfell Tower fire, where local government in an ultra-wealthy London borough appears to have skimped on basic fire protection measures in a social housing block.  Apart from high-profile disasters, the wisdom of the spiritual’s words is evident on a daily basis, although it seldom hits the headlines: in the small city of Stockton-on-Tees in the north of England where I live, differences in male life expectancy between the most and least deprived wards are larger than the national average differences between England and Tanzania.

Life expectancy in Stockton

Outside the high-income world, global health researchers and practitioners constantly confront the realities described in an article on ‘priorities for safe motherhood interventions in resource-scarce settings’.  The authors wrote (in 2010) that the basic interventions recommended by WHO – still far below the standard of care that would be considered normal in the high-income world – would cost US$1.80 per person per year in Uganda, but Uganda was spending only US $0.50 per person on maternal and newborn care.  So, in the health economists’ ubiquitous mantra, priorities must be set.

The researchers who carry out these exercises cannot be faulted, and there is plenty of blame to go around, starting with the fact that a decade later, Uganda’s government was still not meeting  the target of allocating 15 percent of public expenditure to health that was agreed among African Union countries in 2001.  But that is only part of the picture, and it is important to move beyond the familiar vocabulary of resource-scarce settings to ask why some settings are resource-scarce and others not.  Those of us who do so in the academic world are considerably fewer in number than those who take such scarcities as given.  We are not nearly as well funded – the Trades Union Congress and people thrown out of work when transnational corporations relocate contract production from Mexico to China do not fund a lot of research – and (no coincidence) at greater risk of precarious employment.

Nevertheless, we continue to insist that intellectually responsible answers in the global frame of reference must start with colonialism and its legacies.  They must consider more recent historical episodes such as the devastating legacy of structural adjustment programmes that – according to Nobel laureate and former World Bank chief economist Joseph Stiglitz – resulted in ‘a lost quarter-century’ of development in Africa.  A recent study shows that although the World Bank and International Monetary Fund abandoned the vocabulary of structural adjustment around the turn of the century, the relevant practices continue with little change.  Meanwhile, the logic of structural adjustment has been replicated in the decade of (selective) austerity programmes that followed the financial crisis.  Inquiries into the origins of resource scarcity must further consider such factors as the ‘disequalising’ effects of a global economic order that provides abundant opportunities for capital flight, which starves even countries with well intentioned governments of resources needed for health, education, and economic development.

In the contemporary policy environment, one element in particular connects health inequalities around the world:  neoliberalism or, in the words of billionaire investor George Soros (what irony), market fundamentalism. Neoliberalism as a set of norms that guide and justify policy, ultimately equating financial worth with moral worth, conceptually links the dynamics of structural adjustment and capital flight with the fates of the victims in New Orleans and Kensington and Chelsea, and with those of working people quietly living shortened lives of desperation in Stockton-on-Tees (and other deindustrialised communities in the UK, the United States, and elsewhere).  The connections are not only conceptual of course; they are also material and institutional, operating through such channels as campaign money, capital flight and the networks of power and privilege epitomised by the World Economic Forum, where the global super-elite meet to worry about the threat posed to their fortunes by the rest of us.

Daily Mirror cover

Tracing these connections, in contexts half way around the world or as close to home as our local NHS trust in England, is time-consuming and often emotionally draining.  Yet the enterprise is essential to the larger task of demonstrating that neoliberalism is, ultimately and inescapably, deadly – a point clearly understood by at least one media outlet reporting on the Grenfell Tower fire.  Well spotted, say I.

Especially when the context involves social determinants of health, the question of how much evidence suffices to demonstrate this is contested terrain.  Sir Michael Marmot (who chaired the landmark WHO Commission on that topic) and colleagues wrote in 2010 that: ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’.  This is preternatural optimism, as any observer of recent British health inequalities policy will realise, but further discussion must be left for another posting.

This first appeared on the PEAH – Policies for Equitable Access to Health blog

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Income growth in the UK has been weak since the financial crisis. It is a trend which seems likely to continue through to the early 2020s. But in overall terms, this has not been accompanied by a worsening of income inequalities. Official data from the DWP indicate a broad stability in the inequality of disposable household income, equivalised (i.e. weighted) for household composition. In 2006/07, the Gini coefficient before housing costs was 35% and after housing costs it was 39%. In 2015/16, these rates were exactly the same.

Other data published by the ONS actually indicate a slight decrease in income inequality in recent years. According to this data series, the Gini coefficient has fallen from a peak of 36% in 1999-2000, to 35% in 2006-07, to 32% in 2015-16. This is the same level as in 1986, the 1980s being the decade which saw income inequality rise significantly before reaching a plateau in the 1990s.

Britain’s comparative position internationally

According to the standardised data of the OECD, despite a fall in its Gini coefficient from 37% in 2007 to 36% in 2014, the UK is Europe’s most unequal country in terms of disposable income (apart from Estonia). Figures for 2014 (or the latest available) for the other major European countries were: France (29%), Germany (29%), Italy (32.5%), Poland (30%), and Spain (35%). Britain is also the most unequal English-speaking country within the OECD, except the United States.

Contrasting experiences between income and age groups

The ONS figures attribute the marginal reduction of overall income inequality to a rise of incomes of the bottom quintile (the 20% of households with the lowest incomes), and a fall in incomes in the top quintile. The former experienced a rise of £1,600 between 2007/08 and 2015/16 (+13%), while the latter faced a fall of £1,900 (-3%). For all households, the median disposable real income in 2015/16 was £1,000 higher than in 2007/08. According to the Institute for Fiscal Studies, the improvement in low incomes has been due mainly to the performance of the labour market, which experienced strong job growth from late 2013 onwards.

Yet the overall figures mask differences between social groups, especially pensioners and young people. The IFS notes that the median income of the over-60s rose by 11% between 2007-08 and 2014-15. This resulted from an 8% rise in pensioner benefits. But it also stems from real growth in private pensions and increases in employment of older people. In stark contrast, workers aged 22 to 30 have suffered most since the financial crisis: in 2014-15, their real median income was still 7% below the pre-recession level.

Wealth inequality and the impact of housing

Most information about inequality concerns incomes, which are flows and easier to identify. Wealth inequalities by contrast are stocks, and harder to measure. Data are also difficult to come by, as wealth-holders are reticent about declaring their assets. Wealth inequality is, however, a burning issue, as it is far greater than income inequality. According to Rowena Crawford et al., the Gini coefficient of wealth in 2010-12 stood at 64% – nearly twice the income level. Using the latest wave of the Wealth and Assets Survey covering 2010-12, they go on to note that the poorest 1% of households had a net negative wealth of £12,000; the net median wealth was equal to £104,000; while the 95th percentile owned £0.7 million and the top 1% £1.4 million.

In the UK, the question of wealth is particularly important in terms of its impact on housing costs. These tend to aggravate income inequalities as poorer people pay a greater share of their income towards housing. According to DWP data, housing costs have increased the income Gini coefficient by an average 4% since the mid-1990s.

Trends in poverty

The latest figures indicate that median equivalised net disposable income before housing costs in the UK was £481 per week in 2015/16. Taking the 60% threshold of median income as a measure of poverty, the poverty income was thus £288. Respective weekly amounts after housing costs were £413 and £248.

Accordingly, there were 10.4 million people living in relative poverty before housing costs in 2015/16, equal to 16% of the population. After housing costs, these figures rise to 12.8 million. Notably, there has been a slight decline in the last two decades. In 1994/95, 19% of the population was living below the 60% threshold before housing costs; in 2006/07 the figure was 18%. The after housing costs numbers were 24% and 22%.

An alternative measure of poverty shows a greater absolute improvement. When taking the nominal value of the 60% income threshold in 2010/11 and adjusting it for inflation, the number of people living at or below this real level of income after housing costs fell from 41% of the population in 1994/95, to 22% in 2006/07, to 20% in 2015/16.

Future trends and Brexit

While it is still too early to measure the impact of Brexit on inequality and poverty statistics, both the IFS and the Resolution Foundation published studies suggesting that the diverging experiences of pensioners and young people are likely to persist in the medium term. The Resolution Foundation study indicates that higher inflation following the devaluation of the pound will squeeze real incomes, especially for poorer households, while the IFS estimates that earnings growth will favour higher incomes. At the same time, low-income private renters are likely to be hit especially through to the early 2020s.

First published on the British Politics and Policy blog

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Evidence and policy priorities

There are stark ethnic inequalities in health: Black Caribbean, Pakistani, and Bangladeshi people have between six and nine fewer years of disability-free life expectancy than do White British people

Ethnic Minority health

How do we understand this diversity?

Making sense of ethnic inequalities in health – The epidemiological method

‘Epidemiology is the study of the distribution and determinants of disease. The main method of study, particularly for investigating the causes of disease, is to compare populations with different risks of disease. Ethnicity is a variable that is used increasingly to define populations for epidemiological studies.’

Senior and Bhopal (1994)

  • But this encourages an unreflexive and uncritical use of the concept of ethnicity. Ethnic groups are treated as pre-constituted entities with pre-specified properties, with an emphasis on the different/exotic.
  • Explanations are then ‘read’ from the ethnic and disease categories available in data. The presumed properties of ethnic groups, be they cultural or genetic, become the source of explanation for the disease outcome.
  • Rather, we need an approach that pays attention to the processes that lead to the construction and racialisation of ethnic identities, and how these processes shape life chances – what might be called fundamental causes.

Ethnicity, social relationships and social structure

Racial and ethnic groups … are discursive formations, calling into being a language through which differences are accorded social significance, and by which they may be named and explained. What is of importance for social researchers studying race and ethnicity is that such ideas also carry with them material consequences for those who are embraced by them and those who are excluded from them.

Solomos (1998)

The ways in which identities are perceived, valued, mobilised and interacted with are shaped by economic, cultural, legal, political and symbolic resources. Important here is how emotions are attached to symbolic resources, emotions around risk, danger, fear and disgust, which then shape the practices of individuals and institutions. ‘Racial life [is] suffused with shared passions, imageries and fantasies’.

Emirbayer and Desmond 2015

Racism as the fundamental cause

  • Racism has its origins in ongoing historically determined systems of domination that serve to marginalise groups on the base of phenotypic, cultural or symbolic characteristics, thereby generating a racialised social order.
  • Explanation, then, needs to examine the role of three inter-related dimensions of racism – structural, interpersonal and institutional.
  • Structural racism is reflected in disadvantage in access to economic, physical and social resources. This does not have just material implications, but also cultural and ideological dimensions, material inequality justified through symbolic denigration.
  • Interpersonal racism (ranging from everyday slights, through discrimination, to verbal and physical aggression) is a form of violence/trauma and emphasises the devalued status of both those who are directly targeted and those who have similarly racialised identities, thereby engendering meaningful psychosocial stress.
  • Institutional racism (first coined by Carmichael and Hamilton 1967) is reflected in routine processes and procedures that translate into actions that shape the experiences of racialised groups within these institutions.
  • These disadvantages, accumulating across a life course, are the drivers of ethnic inequalities in health outcomes.
Ethnic differences in household income

Ethnic differences in equivalised household income

Low birth weight by occupational class

Low birth weight by occupational class

Standardising for socioeconomic position:

Standardising for socioeconomic position

This reflects both the particular economic location of ethnic minority groups and the multi-dimensional nature of the economic and social inequalities they face, meaning that no realistic statistical adjustment can plausibly simulate randomisation.

Racialised socioeconomic inequalities mean:

  • Lower incomes;
  • Lower status occupations;
  • Poorer employment conditions;
  • Higher rates of unemployment and longer periods of unemployment;
  • Poorer educational outcomes;
  • Concentrated in economically and environmentally depressed areas (but positive effects of ethnic density);
  • Housing tenure;
  • Poorer quality and more overcrowded accommodation.
  • And inequalities that accumulate across the life course and across generations.
Persisting ethnic inequalities in unemployment

Persisting ethnic inequalities in unemployment 1991-2001-2011

Experiences of racism and discrimination:

  • One in eight ethnic minority people experience racial harassment in a year.
  • Repeated racial harassment is a common experience.
  • 25% of ethnic minority people say they are fearful of racial harassment.
  • 20% of ethnic minority people report being refused a job for racial reasons, and almost three-quarters of them say it has happened more than once.
  • 20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
  • White people freely report their own prejudice:
    • One in four say they are prejudiced against Asian people;
    • One in five say they are prejudiced against Caribbean people.

Research across outcomes and contexts consistently shows the adverse impact of racism on health (for example, Wallace et al. 2016

Racism, discrimination and health:

Changes in levels of racism

Changes in levels of racism 1993-2009

Persisting prevalence of racial prejudice

Persisting prevalence of racial prejudice 1983-2013

Institutional racism in health services?

Access to and outcomes of care:

  • No inequalities in access to GP services.
  • No inequalities in outcomes of care for conditions that are largely managed in primary care settings:
    • Hypertension, raised cholesterol and, probably, diabetes.
  • The effect of healthcare systems – a health service with universal access and standardised treatment protocols?
  • Marked inequalities in access to dental services.
  • And marked inequalities in the US insurance based system.
  • And institutional racism evident in some areas:
  • Some inequalities in access to hospital services.
  • Ethnic inequalities in reported levels of satisfaction with care received.
  • And, mental illness and psychiatric services …

Conclusion

  • Racisms are fundamental drivers of observed ethnic inequalities in health.
  • In investigating this, it is important to examine the ways in which structural, interpersonal and institutional racisms operate and constitute one another.
  • Structural conditions of socioeconomic disadvantage and interpersonal experiences of racism both create an increased risk of poor health for ethnic minority people.
  • They also shape encounters with institutions that have policies and practices that lead to unequal outcomes – education, employment, housing, criminal justice, politics, etc., as well as health and social care.
  • Institutional settings represent sites where we see the concentration and mediation of structural forms of disadvantage and interpersonal racism. This is produced via both the unwitting practices and overt agency of individuals operating within particular structural conditions.
  • Institutional racism will take different forms, will operate differently, across institutions with a different focus – for example, the functions of institutions dealing with cancer screening compared with those implementing coercive treatments for severe mental illness.

Reflecting on Policy

  • There has been little development of policy to specifically address ethnic inequalities in health, only occasional, limited and local intervention, with no real evaluation of the impact of specific or general policy on ethnic inequalities in health.
  • For example, a shocking neglect of ethnic inequality in the Marmot Review – assumption that socioeconomic inequalities are unimportant for ethnic inequalities in health, or that general policies to address questions of equity will also address ethnic inequalities.
  • But not a policy vacuum, there are clear policies around identity, culture, community, segregation and migration, all of which are likely to negatively impact on ethnic inequalities in health.
  • And ethnic minority people have been disproportionately impacted on by public sector retrenchment (austerity measures).
  • In fact, the evidence base strongly suggests that policy development should focus on the social and economic inequalities faced by ethnic minority people.
  • Need short term policies to address economic inequality (tax, employment, welfare, housing, etc.).
  • However, the economic inequalities faced by ethnic minority people cannot be addressed by policies targeted at on average reductions in economic inequalities, because such policies don’t address processes impacting on ethnic minority people – reflected in institutional practices.
  • Example: early years investments, which don’t address the emergence and persistence of racial disadvantage in the education system and labour market.
  • Example: failure of favoured ‘up-stream’ interventions, such as SureStart, to engage with and meet the needs of ethnic minority groups.
  • Example: public sector workers bearing the cost of the recession.
  • Example: rise in part-time work and zero hours contracts.
  • Rather need long-term policies that promote equitable life chances and that address racism and the marginalisation of ethnic minority people – a focus on institutions, including politics and Government, is crucial.

Institutional reform: an example

  • As an employer, the public sector has the opportunity to provide significant leadership.
  • For example, in 2017 the NHS directly employed 1.2 million people, indirectly many more, so employment practices within the NHS are able to impact on the labour market nationally and regionally.
  • Ethnic minority people are over-represented in the NHS (and public sector) workforce – 22 per cent of NHS staff are not White, compared with 13 per cent of all workers.
  • Discussion around public sector employment has focussed on enhancing efficiency by reducing labour costs, consequently opening up opportunities for private investment.
  • Instead could use this as an opportunity to implement positive and equitable employment practices, setting a standard: employment rights, holidays, sick leave, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights.
  • Such changes are likely to mostly benefit those in lower employment grades and more precarious employment conditions – ethnic minority workers.
  • Could also address the marked ethnic inequalities within the public sector workforce – ‘snowy white peaks’ – rethinking institutional structures and practices, and addressihng pay differentials.
  • Reforming institutional cultures – the whiteness of institutions – and addressing discrimination and racism in the workplace.

This was presented at our conference Public Health Priorities for Labour

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Labour’s Health Inequalities strategy had some success

Trends in life expectancy

Trends in life expectancy in the most deprived Local Authorities and the rest of England and the absolute difference 1983-2015.

What can we learn from the experience of the programme?

Good points:

  • Cross government
  • increase in equitable investment.
  • Progress on child and pensioner poverty.
  • Technical support for local action.

Bad points

  • Top down.
  • Ignored mental health inequalities.
  • Didn’t address income inequalities, disability poverty.
  • Didn’t empower disadvantaged communities

Priority 1.

Ensure resources for health are distributed to reduce inequalities in life chances between places.

Experience of getting the resources to the right places:

NHS & Local Authority funding per head

NHS & Local Authority funding per head 2002-2016

Funding in London

London does better than the rest of England

What was the impact of the NHS resource allocation policy from 2001 to 2011?

Cuts in council budgets

Cuts in council budgets 2010-2015

  • Review and simplify current systems for allocation of public resources to local areas.
  • Reinstate health inequalities objective for the NHS resource allocation policy.
  • Make reducing inequalities an explicit objective of local government and education allocation formulae.
  • Progressively shifting more resources to disadvantaged places.

Priority 2.

Devolve power – increasing the influence that the public has over how resources are used.

The Devolution Deception

The Devolution Deception

Radical devolution

Priority 3.

Increase the public health benefits of the social security system.

Public Health Toolkit

The benefits budget is twice as big as the health budget

Who gained most….

Poverty trends 1994-2014

This 10 year rise in absolute poverty is unprecedented since records began

  • Prioritize reducing child and disability poverty.
  • Ensure benefit payments provide an adequate income for healthy living.
  • Ensure the benefit processes is supportive and treats people with respect.
  • Reduce conditionality and sanctions.
  • Evaluate the health impact of any changes to the benefits system.

Priority 4.

Develop universal, comprehensive, high-quality early Childhood care and Education.

  • Extend the 30 free hours to all two-year-olds.
  • Provide affordable high-quality childcare through direct government subsidy.
  • Progressive investment to ensure that the places exist to meet demand.
  • Transition to a qualified, graduate-led workforce, by increasing staff wages and enhancing training opportunities.
  • Extending maternity pay to 12 months
  • Halt the closures and increase the amount of money available for Sure Start

So my 4 Priorities for Health Inequalities:

1.Ensure resources for health are distributed to reduce inequalities in life chances between places.

2.Devolve power – increasing the influence that the public has over how resources are used.

3.Increase the public health benefits of the social security system

4.Develop universal, comprehensive, high-quality early Childhood Care and Education.

national health inequalities strategy

and Re-establish a national health inequalities strategy.

This was presented at our conference Public Health Priorities for Labour

 

 

 

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“Almost every day now the media carries stories about inequality and its effects.

In the past few weeks, the Department for Health has confirmed that the health gap between rich and poor in England is growing.

Reports by Lloyds Bank and the Social Market Foundation have drawn attention to our disparities in wealth, with a tenth of adults owning half of the country’s wealth while 15% own nothing or have negative wealth.

Respected independent ‘thinktanks’ like the Institute for Fiscal Studies and the Resolution Foundation have repeated their warnings that, at a time when wages generally are only growing slowly, the combination of tax cuts and cuts in welfare benefits means that income inequality will increase further over the next few years.

“Economic inequality has increased in nearly every advanced Western country…”

This is not just an English or British issue. In March, International Monetary Fund (IMF) researchers estimated that the US economy had lost a year of consumption growth because of increased income polarisation. And of course inequality was a major factor in the Brexit vote and in the election of President Trump.

My interest in the subject was first aroused by my work on the introduction of markets into higher education. I found that the associated increase in competition through mechanisms like tuition fees had exacerbated the inequalities between universities and the constituencies they serve, without any significant compensating benefits. This led me to wonder if there might be parallels in the economy and society more generally.

What I established was that economic inequality has increased in nearly every advanced Western country over the past thirty or so years, and that this has led to a huge range of costs and detriments. Moreover, these costs and detriments are not only social. As the IMF research confirms, increased economic inequality has an economic cost as well. Above all, growing inequality is disabling democratic politics as the concentration of economic power is increasingly reflected in a concentration of political power (as can be seen most clearly in the US).

economic inequality

“Growing inequality is disabling democratic politics…”

But whilst nearly everyone agrees that – to paraphrase Dunning’s famous 1780 Parliamentary motion, economic inequality has increased, is increasing, and ought to be reduced – there is no agreement on how this should be done.

Broadly speaking, there are two schools of thought:

One – the ‘market’ view – is that increased inequality is the inevitable outcome of underlying structural developments such as globalisation, skill-biased technological change, and financialisation (the growing economic role of such processes as banking and securities trading) over which individual countries and governments have little control. These changes are leading to what have been termed ‘winner-take-all’ markets where those at the top gain rewards out of all proportion to their contribution to society.

The alternative, ‘institutional’, theory is that it is due to the political choices made in individual countries, and especially the neoliberal policies of deregulation, privatisation, tax reductions, welfare cutbacks and deflation pursued in most Western countries since the mid- to late-70s, but particularly associated with Margaret Thatcher and Ronald Reagan.

I believe that it is the combination of these underlying structural developments with those neoliberal policies that has driven the post-80s rise in inequality, with the US and Britain well above the other wealthy Western countries in the extent to which inequality has grown there over that period.

So the key to reversing, halting or slowing inequality lies in the first place in reversing these neoliberal policies, but without losing the benefits of properly regulated market competition in sectors where it is appropriate.

The following is a short list of measures that would start to reverse inequality in Britain:

  1. Require the potential impact on inequality to be a major test of every other policy or programme introduced by the Government.
  2. Show that we are serious about tax avoidance by reversing the long-term decline in the number of professional HMRC officials.
  3. Progressively adjust the balance between direct and indirect taxation (VAT), increasing the former and reducing the latter.
  4. Increase the income tax rates for higher earners (say, above £60,000).
  5. Introduce some form of wealth tax.
  6. Begin the rehabilitation of the trade unions by repealing most of the 2016 Trade Union Act.
  7. Reverse the cuts in welfare benefits made by the Coalition and Cameron Governments.
  8. Introduce measures that really will force companies to take account of interests wider than those of top management.
  9. Begin to end segregation in education by removing the charitable status of the private schools.
  10. Focus macroeconomic policy on demand and wage growth rather than inflation and corporate profits.

The Labour election manifesto has some proposals on these lines, but no political party has yet really got its mind round the full range of measures that are needed to combat inequality.

Until they do, inequality will continue to increase.

This was first published on the Policy Press blog

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