Category Archives: Equality

29th February 2020 the chairman of the Commons Health Committee, and former Tory health secretary, Jeremy Hunt said that we need to consider the ‘social and economic trade-offs’ we are willing to make to contain Covid-19.

TUC General Secretary Frances O’Grady has said:

Employers have a duty of care to support workers affected by coronavirus. No one should have to worry about making ends meet if they have to self-isolate or if they fall ill. They should be able to focus on getting better.

The threat of coronavirus shows why sick pay should be a day one right for everybody. It’s unacceptable that millions of UK workers miss out on this protection. The Government must ensure everyone gets statutory sick pay, however much they earn.

The SHA strongly supports the view of the TUC and urges that this scheme is extended to those on ‘self employment’ contracts – part of the 3 million plus ‘Gig economy’. We would argue further that employers should make up SSP to the average pay of workers to ensure they are under absolutely no financial pressure to attend work while they are unwell and may inadvertently pass on the disease.

Should the coronavirus outbreak spread significantly everyone will be expected to respond putting the interests of the community first. Undoubtedly workers will volunteer long hours and take on exceptional responsibilities. This will increase the risk of errors which will need to be balanced against the risk of failure to treat patients in a mass outbreak. We urge professional bodies to be aware of this.

The SHA congratulates trade union and Labour leaders for engaging with the government and employers and instructs our incoming leadership to move very rapidly to promote this position through forceful lobbying, online petitions and other appropriate means.

During the debate important points were raised regarding:

1.) Enforced quarantine – it should be paid in full.

2.) Government requisition private care facilities if circumstances require it.

3.) Government to consider early releases of prisoners not judged to be a risk to society – because of high COVID-19 spread risk in confined overcrowded prison populations (also note criminalisation of sections of society).

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It is truly shocking that life expectancy has stalled in England, and for poorest women it has fallen.  The Marmot Review: 10 years on[1] published this week, shows us in detail how we have failed to improve on most of the indicators that were highlighted in the original review[2] 10 years ago. It points out that this can be clearly linked to the lack of implementation of those evidence-based recommendations.

The report looks at five of the six domains that were used in the 2010 report:

  1. Give every child the best start in life
  2. Enable all children, young people and adults to maximise their  capabilities  and  have  control  of  their lives
  3. Create fair employment and good work for all
  4. Ensure a healthy standard of living for all
  5. Create and develop healthy and sustainable places and communities
  6. Strengthen the role and impact of ill health prevention

It is interesting that they chose not to look at the sixth domain, on the grounds that plenty has been written on this area since 2010, and review was not necessary. This will ensure that there is no opportunity for Government to respond with messages about what it done in this domain, while evidence shows this to be the least cost-effective approach, and hence should have been lowest priority for policy and action.

We know that the top priority should be our children and young people. It is very worrying that infant mortality has increased in the poorest families, that child poverty has increased and now stands at over 4 million. It shows how tax and benefits changes have been deeply regressive, pushing many families into the poverty trap. Knife crime is more common in those areas where youth services have been cut the most. A positive finding is that poor children appear to thrive better in poorer areas than in richer ones: either they are more socially excluded and stressed in affluent areas or that children and education services are doing something right in more deprived areas.

Income is a massively important determinant of health. This report highlights how work is good for health only if it is good quality work. So, although employment has increased, this isn’t enough for people to feel the benefits. The report notes that the average weekly earnings at 2015 prices were £502 in September 2019, only £5 higher than in 2008. The UK is one of only five of the 35 OECD countries where the purchasing power of the average wage has fallen since 2008. Since 2008 there has been a large reduction in benefits available for working age people and children. This, together with the rise in housing costs, has been the driver for huge increases in food bank use. The most deprived households would now have to use over 70% of their disposable income on food if they wanted to follow the Eatwell guide for healthy nutrition.

The report highlights social cohesion throughout, and describes forgotten communities:

“there are   more   areas   of   intense   deprivation   in   the   North, Midlands   and in southern coastal towns than in the rest of England, whilst other parts of England have thrived in the last ten years, these areas have been left ignored. Since 2010 government spending has decreased most in the most deprived places and cuts in services outside health and social care have hit more deprived communities the hardest”

We welcome this report. It confirms the SHA conviction that austerity kills and that the policies of the Conservative-led governments since 2010 have directly led to a heavy burden of increased mortality, ill health and misery that is largely carried by the poor. The most effective actions should have been to address the wider determinants of heath rather than individual behaviour change. Polices have in fact done the opposite of this, including the Government Prevention Green Paper a year ago. This report shows how investment for most things that affect the wider determinants of health has instead been reduced in more deprived communities.

It would be of interest to compare the data collected here with similar analyses in the other devolved nations which have attempted to mitigate the impact of UK wide austerity policies from Westminster.

Prof Sir Marmot says:

‘If health has stopped improving, it’s a sign that society has stopped improving. When a society is flourishing, health tends to flourish’

The SHA realises that there is a very powerful lobby that will undermine this report and all the other emerging evidence, for political reasons.  We know that this report will be challenged by those who support right wing policies, and its conclusions ignored by those with an agenda that doesn’t believe in equity.

We must do all we can to reach agreement again on what a flourishing society looks like. We must change and strengthen our democracy to be more accountable to the multiple views in our communities. The report says

“Our vision is of creating conditions for individuals to take control of their own lives. For some communities this will mean removing structural barriers to participation, for others facilitating and developing capacity and capability through personal and community development”

And as socialists, we believe that the state does have a crucial in protecting and improving the health of its people. For the last 10 years, our Government has been actively undermining the wellbeing of all but the most affluent.

[1] The Marmot Review; 10 years on, Institute of Health Equity http://www.instituteofhealthequity.org/the-marmot-review-10-years-on

[2] Fair Society, Healthy Lives, 2010 Institute of Health Equity http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review

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The Marmot Review 10 years on is being launched today, and is making headlines

Key messages:

  • Over the last decade health inequalities have widened overall, and the amount of time people spend in poor health has increased since 2010.
  • #Marmot2020 confirms an increase in the north/south health gap, where the largest decreases were seen in the most deprived 10% of neighbourhoods in the North East, and the largest increases in the least deprived 10% of neighbourhoods in London.
  • The 10-year on review discounts the theory that the slowdown in life expectancy increase can be solely attributed to severe winters or flu.

You can see the report here

Follow twitter tag #Marmot2020

 

Kathrin

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Make the UK the safest place world to have a baby!

Why is the UK still not in the top ten countries for infant mortality and for maternal deaths? Why? We are a rich country. We have an established high-quality health service. Healthcare is supposed to be accessible to all. How come babies and mothers die or are badly hurt at birth? How come Black and Ethnic minority babies suffer most? Why do poor areas have worse outcomes than wealthy areas? Why is infant mortality rising? (The infant mortality rate is the number of children that die under one year of age in a given year, per 1,000 live births. The neonatal mortality rate is the number of children that die under 28 days of age in a given year, per 1,000 live births. These are both common measures of health care quality, but they are also influenced by social, economic and environmental factors). Are there fundamental problems with core policy documents like the maternity review “Better births”? These are painful questions.

Our campaign wants real improvements for mothers and babies. This posting is not intended as a clinical paper, it is a discussion amongst activists and concerned citizens about where the problems lie. A key set of participants in this discussion are mothers who have given birth, including those who have lost babies, grandmothers and other birth partners, and women who could not conceive.

Our campaign published our Maternity Manifesto during the election but though well shared on Facebook, it did not get into any parties’ manifesto.

We also called a national meeting on issues in maternity care.

What then are the factors that result in UK outcomes at birth worse than other advanced countries?

The answers include shortage of NHS funding, staffing shortages, poor management in some hospitals, staff in fear of speaking out, some policies and procedures, disrespect towards the women carrying the baby, and, as cited in the East Kent enquiry, a lack of practical understanding by staff and by mums of the need to “count the kicks” in the latter part of pregnancy. The introduction of charges for migrant women has also caused deaths. NHS material seems to centre the cause on mothers who smoke, or who are overweight. (Now smoking in pregnancy is plain stupid, it really is, and most mums would not do so if they were not addicted. Don’t do it!). However, other countries, Greece for example, who smoke more, have better outcomes in pregnancy than does the UK. Wider problems like obesity and diabetes, and even women giving birth older, are mentioned in the literature about this. Again, the age of the mother as a factor, but this is only partly true. Giving birth older is often safer than giving birth too young. Globally it is most often young girls who die in childbirth.

Answers may lie in the financially and emotionally vulnerable place that pregnant women occupy in our society, including poverty, violence and stress. Poverty and inequality are factors in infant mortality; “The sustained and unprecedented rise in infant mortality in England from 2014 to 2017 was not experienced evenly across the population. In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100 000 live births per year (95% CI 6 to 42), relative to the previous trend. There was no significant change from the pre-existing trend in the most affluent local authorities. As a result, inequalities in infant mortality increased, with the gap between the most and the least deprived local authority areas widening by 52 deaths per 100 000 births (95% CI 36 to 68). Overall from 2014 to 2017, there were a total of 572 excess infant deaths (95% CI 200 to 944) compared with what would have been expected based on historical trends. We estimated that each 1% increase in child poverty was significantly associated with an extra 5.8 infant deaths per 100 000 live births (95% CI 2.4 to 9.2). The findings suggest that about a third of the increases in infant mortality between 2014 and 2017 can be attributed to rising child poverty (172 deaths, 95% CI 74 to 266).” (Our bold for emphasis).

The UK is a rich advanced country, with a long history of universal healthcare but we have rising infant mortality. “Rising infant mortality is unusual in high-income countries, and international data show that infant mortality has continued to decline in most rich countries in recent years” and “In the most deprived local authorities, the previously declining trend in infant mortality reversed and mortality rose, leading to an additional 24 infant deaths per 100,000 live births per year, relative to the previous trend“.

Poverty is not the sole cause of high Infant Mortality though, Cuba has good outcomes equal to the UK for infant mortality. Cuba is very poor indeed and the UK is one of the wealthiest economies (sadly Cuba does less well on maternal deaths).  

Research shows out of 700,000 births a year in England and Wales, around 5,000 babies are stillborn or die before they are a month old”. 5,000 babies each year. There have been major news stories about baby deaths in many hospitals, notably in ShropshireEast Kent and Morecombe Bay.

Maternal deaths. The UK is not in the top ten countries with the lowest infant mortality rate, neither is it the safest place to give birth. In 2015-17“209 women died during or up to six weeks after pregnancy, from causes associated with their pregnancy, among 2,280,451 women giving birth in the UK. 9.2 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy.” In 2016 The UK ranked 24th in the world in Save the Children’s Mothers’ Index and Country Ranking Norway, Finland, Iceland, Denmark, Sweden, Netherlands, Spain, Germany, Australia, Belgium, Austria, Italy, Switzerland, Singapore, Slovenia, Portugal, New Zealand, Israel, Greece, Canada, Luxembourg, Ireland, and France, all did better than the UK. The situation in some other countries is massively worse than here but that is no excuse. But these baby and mothers’ deaths must stop. We cannot sit back and let these deaths continue.

Let’s be clear, the situation for women in pregnancy and childbirth is massively better than before the NHS, and is head and shoulders better than in the USA today. But maternal mortality is an issue here in the UK, and a huge issue in poorer countries, especially where women give birth without a trained professional being in attendance. Quite rightly professionals and campaigners in the UK participate in international endeavours to improve this situation. The NHS should be training and sending midwives to those countries, instead, it is recruiting midwives from poorer countries. In Europe we have cuts in healthcare through Austerity; in the global south, the same concept of cutting public services to the bone is called Restructuring.

Why is the UK, a rich country with (almost) universal health care not doing better by its mothers and babies? Look at just this case and see the problems in the provision of maternity care;

Archie Batten

Archie Batten died on 1 September 2019, shortly after birth.

When his mother called the hospital to say she was in labour, she was told the QEQM maternity unit was closed and she should drive herself to the trust’s other hospital, the William Harvey in Ashford, about 38 miles away.

This was not feasible and midwives were sent to her home but struggled to deliver the baby and she was transferred by ambulance to QEQM where her son died. Archie’s inquest is scheduled for March. (BBC).

We know that temporarily “closing” maternity units because they are full is a common occurrence. Women then have to go to a different hospital. Induction of labour can be halted because the unit is full. It is not a pleasant situation for mothers. Some maternity units have closed permanently, meaning mothers have to travel further for treatment, at a time when the ambulance service is under great strain (though being in labour is not considered an emergency for the ambulance service!).

Shortage of Midwives and consequent overwork for the existing staff. The UK has a shortage of three thousand five hundred midwives. The midwife workforce is skewed towards older midwives who will retire soon.

Gill Walton, general secretary and chief executive of the Royal College of Midwives said “We know trusts are facing huge pressures to save money demanded by the government, but this cannot be at the expense of safety. We remain 3,500 midwives short in England and if some maternity units regularly have to close their doors it suggests there is an underlying problem around capacity staffing levels.

Training midwives is not just about recruiting new starters to university courses. There need to be sufficient training places in the Hospitals who are already working flat out, leaving little time for mentoring of students, as well as places in the Universities. Alison Edwards, senior lecturer in midwifery at Birmingham City University, who says: ‘It isn’t as simple as recruiting thousands more students as this requires the infrastructure to support it.

‘You need more tutors, more on-site resources and, perhaps more importantly, more mentors and capacity in placement areas – which is currently under immense strain.’ 

One student midwife wrote about her experiences in this letter, where she described very hard work without either pay or good quality mentoring.

The government and the NHS call for Continuity Care from Midwives. This means the same midwife or small team of midwives cares for the mother through her pregnancy, birth and postnatal period. We too believe this would be wonderful if it were possible. It is however impossible with the existing ratio of midwives to mothers. Providing continuity of care to the most vulnerable mothers is a good step. NICE have reduced this to the idea of each woman having a named midwife. One to One a private midwife company claimed to provide this but was unable to continue trading, and went bust leaving the NHS to pick up the pieces.

Nationally the NHS is underfunded and looks set to continue so. Much of the problem comes from a long period of underfunding. We spend less than 9.8 per cent of GDP on health. Switzerland, Germany, France, Sweden, Japan, Canada, Denmark. Belgium Austria Norway and the Netherlands all spend more. That places the UK 13th in the list of high spenders on health care. The US spends 16.9 %. (although a lot of that money is diverted from patient care to the big corporations and insurance companies). The NHS was the most cost-efficient health care service in the world.

Underfunding causes staff shortages. Some errors at birth come from staff being overworked and making mistakes.

Some, our campaign believes, flow from fundamental flaws in government policy such as in the Maternity Review, where the pressure is on staff not to intervene in labour.

 Listen to the Mother. Some of the deaths are from women not being heeded in pregnancy and childbirth. This is backed up in reports from mothers, including some quoted in the big reviews mentioned above. However, overworked and tired staff who know labour like the back of their hand can easily stop heeding an inexperienced mother.

Poverty kills mothers and babies. As we said above, some deaths, poor baby health, and injuries come from growing maternal poverty and ill-health. Low-income families find it hard to afford good food. Food poverty affects a staggering number of children. The charity UNICEF estimates that “2.5m British children, or 19%, now live in food-insecure households. This means that there are times when their family doesn’t have enough money to acquire enough food, or they cannot buy the full variety of foods needed for a healthy diet. In addition, 10% of these children are also classified as living in severe food insecurity (the European average is 4%) and as a result, are set to experience adverse health.”

Studies show that;

The Independent inquiry into inequalities in health (Acheson 1998) found that a child’s long term health was related to the nutrition and physique of his/her mother. Infants whose mothers were obese had a greater risk of subsequent coronary heart disease. Low birth weight (under 2500 g) was associated with increased risk of death in infancy and with increased risk of coronary heart disease, diabetes and hypertension in later life. Accordingly, the Inquiry recommended, ‘improving the health and nutrition of women of childbearing age and their children, with priority given to the elimination of food poverty and the reduction of obesity’. (NICE )

A significant number of deaths of new mothers come from mental health issues that spiral out of control. Some of these will be newly developed conditions and some existing conditions made worse by pregnancy and childbirth. Mothers family and professionals must all be on the alert and intervene early. There are good ways to treat mental health in pregnancy.

Reducing the social and economic stresses around pregnancy would also help reduce the deaths and suffering

When Birth goes wrong it can be a dreadful experience for everyone involved. In most cases, the panic button brings in a well-drilled team of experts who can solve nearly every problem and do it calmly. At other times, it is dreadful, as described in the coverage of the birth and death of baby Harry Richford. Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital in Margate in 2017 but died a week later. https://www.bbc.co.uk/news/uk-england-kent-51097200

Sands, the baby death charity explains that there are many causes of babies dying before birth. Crucially important is that mothers are heeded when they are concerned and that everyone Counts the Kicks

 

Maternity is not the only area of the NHS that suffers. There have been serious mistakes in NHS planning including closing far too many beds. The NHS closed 17,000 beds and now is working beyond safe bed occupancy. There are 100,000 staff vacancies. Waiting times in A and E are dreadful, as are waiting times for cancer treatment. NHS managers and the Government have taken the NHS far from the Bevan model of healthcare (for history read this).

Press coverage. How does the press cover the NHS, and baby deaths? There are very real problems in the NHS and maternity care but the coverage in the press of these problems seems to switch on and off in strange ways, often to suit Conservative Party political requirements. The NHS and the Government are masters of propaganda and news manipulation. The public needs to learn to judge the news and to look both for actual problems and look out for bullshit and manipulation. Why was news of the arrest of the nurse from the Countess of Chester hospital headlines on the 70th Anniversary of the NHS? Why was the news of the understaffing there not given similar nationwide publicity? Why have we heard little or nothing since?

If the government can switch the blame to the professionals in the NHS (but not their mates the high admin of the NHS), then they seem to be happy to publicise the problems. In other cases, problems are swept under the carpet.

Professionals expect to (and do) take responsibility for their own actions. Mistakes will be made. It is impossible to go through life without some mistakes. When we are dealing with life and death mistakes can be catastrophic, even where there is no ill intent.

Malicious action is rare.   There are the terrible cases of serial murderer Harold Shipman, and the convicted surgeon Ian Paterson who falsely told women, they had breast cancer and operated on them unnecessarily. The hierarchical system in the NHS and the lack of regulation in private hospital, which was described as “dysfunctional at almost every level” allowed that harmWe have not found such a case in maternity.

Unintentional bad practice, however, has also harmed babies. No one went to work intending to harm in the events publicised in the Morecombe Bay Enquiry into the deaths of 11 babies and one mother. It was said that “The prime responsibility for ensuring the safety of clinical services rests with the clinicians who provide them, and those associated with the unit failed to discharge this duty over a prolonged period. The prime responsibility for ensuring that they provide safe services and that the warning signs of departure from standards are picked up and acted upon lies with the Trust, the body statutorily responsible for those services.”

The Enquiry described what happens like this “In the maternity services at Furness General Hospital, this ‘drift’ involved a particularly dangerous combination of declining clinical skills and knowledge, a drive to achieve normal childbirth ‘whatever the cost’ and a reckless approach to detecting and managing mothers and babies at higher risk.”

The Furness General Hospital was pushing for Foundation Trust status at the time and was not exercising the necessary supervision.

“Maternity care is almost unique amongst NHS services: the majority of those using it are not ill but going through a sequence of normal physiological changes that usually culminate in two healthy individuals. In consequence, the safety of maternity care depends crucially on maintaining vigilance for early warning of any departure from normality and on taking the right, timely action when it is detected. The corollary is that, if those standards are not met, it may be some time before one or more adverse events occur; given their relative scarcity in maternity care, it is vital that every such occurrence is examined to see why it happened.

So, many factors come into play in such incidents of harm to mother and baby. Professionals too can be emotionally wrecked by tragedy.

Huge personal and professional lessons can be learned from a detailed review of cases where mistakes are made. There is a whole literature about learning from mistakes. The worst such incidents are referred to as Never Events. This is just one article about such errors but there is a whole field of research devoted to it. Serious Mistake Reviews often happen at the end of shifts, and in the worst cases, may lead to long public enquiries.

NHS as a research organisation One of the great virtues of the NHS is the research base it offers professionals. What happens in the NHS which covers 62 million people is studied, evaluated, and researched. This is invaluable to staff and above all to patients. Sadly this research is also of interest to big business especially to those who sell health insurance and to the big corporations who have their ‘snouts’ in the NHS ‘trough’. Research for the common good is clearly different from research to make money. We see that regularly in big pharma. Cheap effective medicines do not make money for the companies. Yet the government is giving away our medical data to companies to make a profit.

There are also “errors” that happen when everyone is following accepted procedures and protocols; “untoward events, complications, and mishaps that resulted from acceptable diagnostic or therapeutic practice”. Procedures within the NHS can be robust and well researched, and problems still occur.

https://www.mamaacademy.org.uk/news/mbrrace-saving-lives-improving-mothers-care-2019/

Research matters. Only by studying outcomes can these errors be revealed. A classic example is the once customary practice of episiotomy, cutting a woman to prevent tears to the perineal skin in childbirth, which is now no longer used except in an emergency. Research both formal and informal changed that practice. As another example of such research, Liverpool Women’s hospital has been involved in research about the benefits of leaving the baby attached by the cord if they are born unwell. NHS staff and other health professionals, academics and pressure groups are working hard to improve outcomes for mothers and babies. Each mothers death is reviewed in the MBRRACE-UK report

https://mamadoc.co.uk/the-maternal-mortality-report-we-should-all-learn-from/

Never again. The tragedy of the death of a mother and or baby is felt by that whole extended family. Most families want to know it will never happen again. Cover-ups and lies mean it will happen again, so brutal honesty is needed.

 

The aftermath of medical treatment or neglect which causes real harm is complex. Whether the outcome is death, life long impairment, or long term physical and mental health issues, these are very significant events for all concerned.

Campaigners in Liverpool campaign for SEN funding to be returned. 2019

If a baby is born with life-changing impairments, the baby is left facing catastrophic difficulties and the mother and family can face major heartbreak and hardship. The huge love we have for our kids (may it long continue), whatever their issues, does not prevent the financial, housing and employment issues families with disabled children face. Nor does it guarantee the best educational opportunities, SEN is being battered by cuts. but parents and teachers are fighting back.

 

The cost of financial “compensation” from an injury to a newborn is huge because it is life long. The cost of this “compensation” used to be carried by the government but the system changed to make hospitals “buy” insurance from a government body which is set up like an insurance company. The cost to the hospital is charged on the basis or earlier claims, like car insurance. Obstetrics make the highest claims of any section of the NHS.

Liverpool Women’s Hospital had a huge case (not about babies) some years ago, arising from a surgeon who left many women damaged after incontinence operations. Their total bill, over 5 years, according to the Echo, was £58.8 million. “The NHS trust has been forced to pay out £58.8m in the last five years for both recent and historic negligence cases.

The limited work we do, as a campaign, in holding the hospital to account, leads us to believe lessons have been learned by the hospital. However, in every hospital, there are pressures which could lead to problems. These pressures include financial and organisational, problems of management ethos, and the potential for bullying, the distrust by the staff of their management, and disrespect for whistleblowers.

The NHS has gone through years of reorganisation after reorganisation. In that time the financial and government pressure has been to complete the re-organisation, or face catastrophic consequences so very many hours of admin and senior doctor time has been wasted on this process. That time could have been focussing on saving babies.

At STP and national level, there are other problems. The NHS is intensely political. There are deep structural problems. (We believe the NHS should return to the Bevan Model of health care)

The NHS is not only deprived of adequate funding, but it has also been forced to implement many market-based changes, including the internal market, outsourcing and commissions of services to for-profit companies. These market-based structures are expensive.

The NHS has also seen dire staff shortages resulting from stupid decisions like removing bursaries, not training enough doctors and the hostile environment to migrant staff.

There are moral and financial issues in all cases of such errors. The hurt to the babies is our priority.

Baby deaths and severe injury at birth have complex roots. Though what happens in the hospital is crucial, it is not just what happens in the hospitals that matter. The stress, poverty and anxiety many mothers endure during pregnancy do sometimes affect the outcomes for the child. Many women are still sacked for being pregnant but families can rarely cope with just one wage (do fight back against sacking pregnant women!). See Maternity Action for details. Both mums and midwives can call Maternity Action for advice.

Low pay or the dreaded universal credit can make food heating and rent all too expensive. This can lead to food poverty. Women do not yet have real equal pay but mothers have the worst pay of all  Benefits are no longer allowed for a third child. even though most claimants are working. Whether parents are working or not, every child has a right to food and shelter, be they first or 10th child. The child gets no choice!

Not every pregnant woman is in a stable caring relationship. Housing, especially private renting, becomes more difficult when women are pregnant. Who can forget the story of the homeless woman giving birth to twins in the street? Pregnancy is often the time when domestic violence is inflicted on a woman but it is the time when women are least able to walk away. Poverty kills babies too.

Please join us in campaigning for better outcomes for all mothers and babies in the NHS and across the globe. We want this to start a discussion, so please send us your views. and information

 

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This article was first published in the Camden New Journal under the title, Brexit, and spectre of NHS US sell-off, on 16 May 2019.

There is much talk at the moment about the prospect of Brexit resulting in a trade deal with the US which will sell off our NHS to American private healthcare providers.

This fear has also been expressed by Shadow Health Secretary Jonathan Ashworth. [1] But it is critical to understand this “sell-off deal” has been under way for a long time and is fast gaining momentum, argue Susanna Mitchell and Roy Trevelion.

 

The driver of the “sell-off deal” is Simon Stevens, who in 2014 was appointed head of NHS England, the body that controls all NHS spending. Before this, Stevens had been vice-president and CEO of the mammoth American healthcare corporation the UnitedHealth Group.

Stevens has proceeded to “Americanise” the service through his subsequent NHS policy, based on a privatisation strategy he had outlined at the World Economic Forum at Davos in 2012. [2]

From first to last, his NHS policy – the Five Year Forward View, the Sustainability and Transformation Plans and Accountable Care Organisations (renamed Integrated Care Programmes) that back it up, and now the 10-year Long Term Plan – have worked to import the US model into the UK.

Unsurprisingly, the UnitedHealth Group will make major gains from this transformation. It is now the largest healthcare company in the world, with a 2018 revenue of $226.2 billion. It has many secondary companies that serve more than a hundred-million people globally. [3]

Over the years it has been prosecuted for fraud and bad faith practices. This included limiting insurance payments to doctors, and not stating its true financial results in reports to shareholders. [4] [5]

One of its fastest growing subsidiaries is Optum (formerly UnitedHealth UK). This is a leading information technology- enabled health services business. In February 2015, it was one of the commercial organisations approved by NHS England as “Lead Providers” to carry out the financial work of GPs.

It is now firmly positioned in the system and ready to take away more public money. [6]

The healthcare system in the United States is hugely more costly, and outstandingly less effective than that in the UK. In terms of funding and wellbeing, there is no rational argument for imposing it on our NHS. The only benefit it brings is increased profits for shareholders in the commercial healthcare sector.

To take three examples, first comparing cost:

On average, other wealthy developed countries spend about half as much per person on health as the US – in the US $10,224 compared to $4,246 in the UK. In 2017 the US federal government spent 7.9 per cent of GDP directly or indirectly on healthcare; however in total, taking into account private expenditure, the US spent a vast $3.5trillion or 18 per cent of GDP. This private sector spending is triple that of comparable countries. [7] [8]  This structure excludes many citizens from affordable health­care. Appallingly, one in four adults skipped a medical treatment in 2017 due to an inability to pay. [9]

Secondly, from the point of view of efficacy and wellbeing, statistics are also devastating. The US has the lowest life expectancy at birth among comparable countries (US 78.6, UK 81.2). Statistics show that life expectancy for both men and women has increased more slowly in the US. It comes 12th in the global life expectancy table. [10]

Thirdly, the US maternal mortality rate is truly shocking. It stands at 26.4 per 100,000 live births, the worst among all developed countries. [11]

In the UK the rate stands at 9.2 per 100,000. [12] [13]

Deaths for African-American women are three to four times higher than for white women. [14]

The infant mortality rate is also worse. The US rate is 5.79 deaths per 1,000 live births. [15]  The UK rate is 3.8 deaths per 1,000 live births. [16]

It is clear that if we follow the American model of healthcare it can only reduce wellbeing in the UK. Simon Stevens’ “sell-off deal” simply increases the wealth of global corporations (such as the Mayo Clinic, which has recently opened in London [17]).

It is time that this fact was “called out” loudly and clearly. All possible measures must be taken to prevent the continuing imposition of this ineffec­tive and costly system.

Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.
References, some links, live at the time of writing, may not have been maintained:
[1] BBC Question Time 25.04.2019  at 47.21 ff  https://www.bbc.co.uk/iplayer/episode/m0004hkk/question-time-2019-25042019 .
[2] https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/
[3] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
[4] https://www.sec.gov/news/press/2008/2008-302.htm
[5] https://law.freeadvice.com/insurance_law/insurers_bad_faith/unitedhealth-pays-400-million-in-bad-faith-claim.htm
[6] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
[7] https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
[8] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
[9] https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
[10] https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-le_the-u-s-has-the-lowest-life-expectancy-at-birth-among-comparable-countries_2019
[11] https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1560004210914
[12] https://vizhub.healthdata.org/sdg/
[13] http://digg.com/2017/uk-birth-us-safety-comparison
[14] https://www.huffingtonpost.co.uk/entry/elizabeth-warren-black-maternal-mortality_n_5cc0e93fe4b0ad77ff7f717b?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACQmWXh6QTnSJI5sjLN1KEdQCuSnVb__LEQLJAyEiK2PZwqnVABYxo500JrU24NHWCooflTZAia50H4OJ-YzSPMUqXyGODWHMGcBXUxhfVY-fau-ViM-Ly9n32SQ1vXD-SGhWXohZRVo2givDSEbM1D3TVs38R5MjmfY_5rGZXuP&guccounter=2
[15] https://www.cdc.gov/nchs/nvss/deaths.htm
[16]https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2016
[17] https://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnershiphttps://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnership.

 

 

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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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