The NHS Role in Tackling Health Inequalities

At the turn of the 21st century, social health inequalities remain to be the key public health problems in advanced European countries. There is strong variation in life expectancy between and within the countries, which has accumulated over the past 3 or 4 decades' (Fox, 1989; Drever & Whitehead, 1997; Kunst, 1997; Marmot & Wilkinson, 1999; Elstad, 2000; Mackenbach & Bakker, 2002). NHS targeted health inequalities with infant mortality and life expectancy at the core to reduce them by 10 % by the end of 2010. These two health inequalities were announced in February 2001, with the other complementary targets, the areas of smoking and teenage pregnancy. These targets were set to reduce the broad spectrum of inequalities covering the general strategy to address all of the major health inequalities including gender, race, age, etc.' (DH, 2001).

The secretary of state, nationally announced a comprehensive strategy to reduce health inequalities, challenging the NHS as a key player to live up to its founding and enduring values of universality and fairness to shut the unjustified gaps between individuals with any background, fair NHS services with high quality and good outcomes to everyone' (Darzi L., 2007).

The independent scientific review of the national health inequalities was published in 1998. This report suggested policy developments to tackle health inequalities. This report showed the increasing gap between the different social groups. This resulted in the consideration of these increasing gaps needed action 'upstream' as well as 'downstream' (Acheson Inquiry, 1998).

As the NHS and Department of Health continuously poured efforts to reduce the health inequalities. The overall performance can be defined as 'much achieved more to do' (DH, 2009).

This review will analyze the role of NHS in tackling health inequalities, as targets were set to reduce infant mortality and to increase the life expectancy in men and women across UK, faster than elsewhere in world.

2.0 Aims:

• To understand health inequalities
• To briefly review of the Acheson Inquiry recommendations
• To study the role of the NHS as a key player in tackling health inequalities in UK.

3.0 Material Methods:

Study will review reports and documents published by the Department of Health and the NHS. Review of literature will be done from the data available on the websites of the Department of Health, the NHS and other government websites. Discussion of role of NHS as key player in tackling health inequalities in UK and a comment on the target achieved over a decade.

4.0 Review of Literature:

In 1980, the United Kingdom Department of Health and Social Security published a report of the Working Group on Inequalities in Health, also known as Black Report. This report showed great extent of of which ill-health and death are unequally distributed among the population of Britain, and suggested that these inequalities have been widening rather than diminishing since the establishment of the NHS in 1948'(Gray AM. 1982). The Black report identified four types of explanations of health inequalities: artefact, selection, cultural or behavioural, and materialist' (Blane D., 1985). Since then there were many studies contributed to broader understanding of the health inequalities (Smith et al 1990). After 1997 NHS had made clear progress, as in 1997 NHS was in relatively poor health, due to this low investment hampered proper planning. In regards with different health inequalities NHS was not simply big enough or capable enough to meet the expectations of the patients (Darzi L., 2007).

The steepest inequalities health is observed at two stages of the life course: early childhood and midlife. Less inequality is observed in adolescence and in older age (Kuh & Ben Shlomo, 1997). Actual health inequalities were considered and taken note by the scientific independent inquiry called as Acheson Report in November 1998, which reviewed the evidence of health inequalities in UK. Acheson report suggested that, "there is convincing evidence that, provided an appropriate agenda of policies can be defined and given priority, many of these inequalities are remediable (Acheson Inquiry, 1998).

The Acheson report is supposed to be the cornerstone for the policy development over the last 11 years informing action on the national target and the cross-government strategy, the programme of action. The report focused on socio-economic inequalities which showed the increasing gap between different social groups. It suggested almost 39 recommendations (Appendix I).

After considering the all the facts and recommendations, the NHS announced the two national health inequalities targets in February 2001, one relating to the infant mortality and the other to life expectancy. These targets were considered to reflect the efforts taken to reduce the broad spectrum of inequalities at national level across UK. These targets can be formulated under the specific terms - socio-economic groups and geographical areas so that they can cover more general strategy to address all of the major health inequalities including gender, race, age as well as health in specific disadvantaged groups such as lone parents and the homeless (DH, 2001).

England's new health strategy, like this across the UK, represents a major advance in the vision and remit of public health policy. Protecting and improving aggregate levels of health no longer provide a sufficient justification for investment in public health; this investment must also yield a more equal distribution of health between socioeconomic groups. As a result, public health goals which were previously expressed only in terms of population averages now include a concern with how health is distributed across society. It is a concern summed up in the goal of 'tackling health inequality' (Hilary G., 2004).

5.0 Understanding Health Inequalities:

Inequalities are a matter of life and death, of health and sickness, of well-being and misery. The fact that in UK today people in different social circumstances experience avoidable differences in health, well-being and length of life is, quite simply, unfair. Inequalities in health arise because of inequalities in society - in the conditions in which people are born, grow, live, work, and age. So close is the link between particular social and economic features of society and the distribution of health among the population, that the magnitude of health inequalities is a good marker of progress towards creating a fairer society (Marmot, 2010).

The documents on plans, actions and performance standards are designed to spell out what it means to tackle socioeconomic inequalities in health. Their descriptions suggest that it has a variety of meanings. At some points, tackling health inequalities is described as a commitment 'to break the link between poverty and ill health' and 'to improve the health of the worst off ' (Milburn, 2001 as Cited in Hilary G., 2004). Health inequalities can be stated as 'the disparity in health status between rich and poor' and 'the health gap between the worst off in society and the better off' (Wanless D., 2001). At other points, health inequality is a concept which covers the whole population. Health inequality 'exists between social classes' and 'right across the spectrum of advantage and disadvantage' (Hilary G., 2004).

6.0 Review of Acheson Report:

The Acheson report was published in 1998 from then it has been considered as the corner stone for tackling health inequalities. This independent scientific review considered the developments over the 20 years and identified some possible policy developments to address health inequalities. The report showed the data with increasing gap between social groups, "in early 1970s, the mortality rate among the men of the working age was almost twice as high as for those working in social class V (unskilled) as for those in social class I (professional). By the earlier 1990s, it was almost three times higher." This resulted in the consideration of this increasing gap needed action 'upstream' as well as 'downstream' in other words from outside the NHS, as well as within it.

The report also addressed that social determinants affect people's health across their lives; the early years are a particularly important stage of life, where poor socio-economic circumstances have long lasting effects. Consequently, it gave priority to policies and interventions with the potential to reduce inequalities in access to the determinants of good health among parents, particularly present and future mothers, and children.

It suggested almost 39 recommendations (Appendix I) which focus around the 4 major themes:

The social determinants of health, such as poverty and income, education, employment, environment and housing

The life course, including lifestyle factors such as smoking, nutrition and alcohol consumption

Other dimensions of health inequalities beyond socio-economic status namely ethnicity, gender and age

Measures to improve the effectiveness of the NHS's systems of care, not least in terms of resources and access to services.

The report gave high priority to mothers, children and families. Tackling health inequalities is a complex and long-term challenge, requiring action across the layers which influence the health. The relationship between these layers is shown below in Fig. 1 (an updated version of the Dahlgren and Whitehead diagram that appeared in the Acheson report).

Fig. 1 The main determinants of health:

Source: Barton and Grant (2006) adaptation of Dahlgren and Whitehead (1991) from UN Economic Commission for Europe (2007) Resource Manual to Support Application of the Protocol on Strategic Environment Assessment.

7.0 National Health Inequalities Strategy, Programme for Action:

The national health inequalities target was set in 2001 the aim was to reduce the health outcomes in infant and the overall increase in life expectancy by 2010. The national health inequalities strategy programme for action was built on the board front set out in Acheson, which focused on the importance of the working across government and in partnership both with other service providers and with the local communities' (DH, 2003).

Four themes of the programme for action:

supporting families, mothers and children - reflecting the high priority given to them in the Acheson report

engaging communities and individuals - strengthening capacity to tackle local problems and pools of deprivation, alongside national programmes to address the needs of local communities and socially excluded groups

preventing illness and providing effective treatment and care - by means of tobacco policies, improvements in primary care and tackling the 'big killers' coronary heart disease (CHD) and cancer

addressing the underlying social determinants of health - emphasising the need for concerted action across government at national and local levels up to and beyond the 2010 target date.

Annual status report has to be published throughout the lifetime of strategy, these developments were monitored against the NHS to the wider determinants of health (reflecting Acheson's proposal for action on broad front), and 82 departmental commitments (DH, 2003)

These Annual status reports showed the improvement in health in real terms across all social groups, against a range of indicators including life expectancy, infant mortality, cardiovascular disease and cancer, and reported on developments against the cross-departmental commitments (DH, 2010).

8.0 Role of the NHS in tackling health inequalities:

As NHS is the key player in tackling health inequalities target set in 2001- 'By 2010 to reduce the inequalities in health outcomes by 10% as measured by the infant mortality and life expectancy at birth.'

8.1 Life expectancy-

The life expectancy gap between the areas with lowest life expectancy and the national average is caused principally by premature deaths from cancer, circulatory diseases and respiratory diseases with smaller effects from suicide and violence in men. The over 50s contribute 79% of the gap in women and 70% of the gap in men. It follows that the priorities for NHS action which will have the greatest impact on narrowing the gap are:

• addressing cancer and circulatory diseases within manual social groups because these major killers exhibit strong social class gradients.
• Improving the life expectancy of the over 50s
• high quality care in disadvantaged areas, especially primary care.

Key areas of interventions to narrow the gap in life expectancy are: reducing smoking, prevention and effective management of other risk factors in primary care, targeting over-50s, and working pro-actively with partners on issues affecting life expectancy.

8.2 Infant mortality-

Deaths under one year of age total about 3,000 per year. The two major causes of neonatal deaths are 'immaturity related conditions' and 'congenital malformations' and both show a strong social class gradient. The social class gradient is greater for post-neonatal deaths. Just under 50% of all post-neonatal deaths are accounted for by two causes: 'signs, symptoms and ill-defined conditions' (predominantly SIDS) and congenital anomalies.

The underlying determinants of mortality and ill-health in infants include:

• low birth weight
• maternal smoking (smoking during pregnancy)
• paternal smoking
• maternal anthropometry/nutritional status
• failure to breast feed
• quality and quantity of health care
• maternal age
• the physical environment (housing condition)
• the family and social environment

Key areas for interventions to narrow the gap in infant mortality are: reducing smoking in pregnancy, improving nutrition in women, reducing teenage pregnancy, increasing breast-feeding, effective ante-natal care, improving the quality of midwifery, obstetric and neonatal services and high quality family support.

The NHS set to improve the action to address health inequalities (Appendix II):

• Raise the profile of health inequalities and focusing on results
• Making it clear it is not good enough to achieve top line targets at the expense of widening inequalities
• Make health inequalities an integral part of planning, commissioning and delivery
• Promote Health Equity Audit, Local Delivery Plan and its impact on the health inequalities.
• Partnership working and influencing partners to tackle the wider determinants of health and health inequalities
• Progress must be measured
• Use of the Health Care Standards and their underpinning criteria.

The WHO guiding principle, that 'the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being', was reiterated in the 1998 World Health Declaration' (Hilary G., 2004). The report on health profile of England 2009 states there are improvements in number of critical areas eg. Decrease in mortality rates, increase in life expectancy and further reduction in infant and perinatal mortality' (DH, 2010). These achievements can be defined as 'much achieved more to do'(DH, 2009). Now the NHS is focusing to be the World Class NHS whom services will be' (Darzi L., 2007)-

• Fair
• Personalized
• Effective
• Safe

Over recent years health inequalities have increasingly featured as an NHS priority. This has been evident in their incorporation into other Public Service Agreement health targets, and the findings of the Wanless report noted the association between lower socio-economic status and poor health outcomes, and the cost consequences for the NHS' (Wanless D., 2004).

The contribution of the NHS to the 2010 target was recognized in the Treasury-led cross cutting review (DH, 2002). This review considered the implications of the Acheson report for departments across government and the NHS. It identified NHS interventions as more likely than other interventions to help deliver the short-term target through reducing smoking in manual groups and preventing and managing other risk factors for coronary heart disease and cancer, but it recognised that the social determinants were crucial for a long-term sustainable reduction in health inequalities.

9.0 Discussion:

The Black Report concluded that inequalities in early 1980s were not mainly attributable to failings in the NHS, but rather to many other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work. Then Black Report recommended a wide strategy of social policy measures to combat inequalities in health. After 10 years of Black report the social class differences in mortality were still increasing, after this there were many studies undertaken addressing inequalities in health'(Smith et al 1990). Then Acheson report was published in 1998 an independent scientific review of the inequalities in health, and in 2001 the national targets for tackling inequalities in health were set in which Department of Health and NHS played a key role the success can be stated as the 'much achieved more to do' (DH, 2009). The Marmot review recommends 'action on health inequalities requires action across all the social determinants of health and needs to involve all central and local government departments as well as the third and private sectors. Action taken by the Department of Health and the NHS alone will not reduce health inequalities' (Marmot, 2010).

10.0 Conclusion:

The above study shows the NHS had played a key role in tackling health inequalities along with the Department of Health over the past decade. This resulted in the highest life expectancy ever in UK and gradual decrease in the infant mortality. Overall development in past decade is shown in Appendix III, which shows factors such as employment, housing conditions, educational achievement, crime and child poverty without which the overall improvement in the health inequalities is not possible. The role of NHS in tackling health inequalities have also improved the overall performance of the NHS itself in and made the NHS a World Class NHS visioning fair, personalized, effective and safe services ahead.