Policy on Health Inequalities in the UK - Essay Example

Running Head: HEALTH INEQUALITY Health Inequality s Health Inequality Introduction Health inequalities are moving up the policy agenda of post-industrial societies. Within and beyond Europe, public health policy is being reconfigured around the goal of reducing socio-economic differentials. It is a goal, which is driving new health strategies in the United Kingdom (UK), with the government committed 'to narrow the health gap in childhood and throughout life between socio-economic groups' (Secretary of State, 2000, pp. 166 and 167). At the same time, reducing health inequalities has been incorporated into Italy's 2000-2000 National Health Plan and Sweden is developing a health strategy structured around measurable equity targets (Ministero della Sanita, 2000; National Public Health Commission, 2000). Looking beyond Europe, New Zealand has launched a new health strategy to deliver reductions in health inequalities (King, 2000). These national initiatives are framed by the international equity agenda established by WHO in its Health For All charter and reaffirmed in its Health21 programme (WHO and WHO). The English healthcare system espouses objectives of equity, usually expressed as equality of access for equal need. The right to access is established in common law and any health organisation denying it would face judicial challenge. The attainment of this objective needs to be assessed by the degree of equity achieved in the distribution of resources, the outputs of health services and outcomes in terms of health improvement. Discussion In the UK, policy on health inequalities has been gathering pace since the late 1990s. Renewed interest in this subject began when the UK government commissioned an independent inquiry into inequalities in health in 20031. This interest continued after three key events. A major new perspective on the income and health relationship is provided by the evidence that population mortality rates are strongly related to the degree of income inequality in a population. This has been demonstrated repeatedly with international data and has most recently been reported among the various states of the United Kingdom: more egalitarian countries and states have lower mortality rates. It has been suggested that the reason more egalitarian societies have better health may be that they tend to be more socially cohesive. There are a number of examples of egalitarian, healthy, and cohesive societies, ranging from Roseto in Pennsylvania to Japan and to Britain during the two world wars. In each, unusually cohesive social relations may have been protective of health. However, given the qualitative and circumstantial nature of this evidence, the paper by Kawachi and colleagues (Kawachi et al. 2004) in this issue6 is particularly exciting. It provides the first quantitative evidence that aspects of social cohesion may indeed link smaller income differences to lower mortality rates. The results of Kawachi et al. seem to suggest that where income differences are smaller, people experience their social environment as less hostile and more hospitable. (Kawachi et al. 2004) That income inequality is related particularly closely to deaths from homicide, accidents (unintentional injuries), and alcohol-related causes points toward pathways mediated by failing social cohesion. Work on social support and social affiliations have shown the importance of the social environment to health. (Campbell 2003) As other human beings have always had the potential to be our most feared adversaries and competitors as well as our greatest source of comfort and solace, it would be understandable if the nature of the social environment were crucial to our psychosocial welfare and the prevalence of chronic stress in populations. (Mohan 2000) Distribution of resources The allocation of financial resources continues to be based on refinement of the Resource Allocation Working Party (RAWP) formula first introduced in 1976 . This is calculated based on population weighted by proxies of health need including demographic profiles, and, despite some criticism and this formula is generally accepted as equitable . Since 2002, allocations have been made directly to Primary Care Trusts (PCTs). The comparison of present allocation versus 'ideal' target allocation gives an indication of the degree of inequity. The policy set for the period 2002-2005 moves all PCTs towards their target allocation, through a combination of a capped increase for over-resourced districts of around 8.5% per annum (still well in excess of inflation) and significantly greater increases of up to 14% for under-resourced districts. (Carrhill 2001) The effect of this will be that at the end of the period only four (of 302) PCTs are anticipated to remain more than 10% under target, and eleven PCTs more than 10% over target . Similarly, there has been recognition of the inequity of distribution of human and physical resources. The NHS Plan sets challenging objectives for increasing the number of health care staff. Targets have been set for strategic health authorities in proportion to the base differential from national comparator benchmarks for specific cadres e.g. numbers of community nurses or hospital consultants. The rationale for such targets can, however, be questioned especially as health service modernisation drives skill-mix changes making historically based comparators, focusing on the availability of single professions, difficult to interpret. Specific financial incentives were introduced through 'golden hellos' to encourage GPs to take up appointments in more deprived areas. However, the effectiveness of these in contributing to greater equity was limited and the scheme was withdrawn in April 2005. This reflects a shift towards addressing resource management issues at local rather than national level, and a realisation that equity of outputs and outcomes are of greater importance than attempted national micro-management of inputs. Strategic health authorities allocate capital resources to trusts, although the majority of capital in the health service is now controversially raised through private finance initiatives (PFI) with concerns both about privatisation of the NHS and about potential for overextension of recurrent commitments. Allocation of public capital is dependent upon a variety of factors, such as existing building stock, making direct equity analysis complex. The most glaring examples of estates inequity occur within primary care services, in inner city areas. To respond to this, legislation has been enacted to allow the establishment of Local Investment Finance Trusts (LIFT), a public/private partnership focused on producing increased capital resources for community-based services. It remains too early to evaluate the effectiveness of such initiatives, though it has attracted criticism including a concern that this is likely to result in for-profit ownership and leasing of primary care facilities with potential for misalignment with population health needs . Relative Incomes The contrasting relationship between income and mortality within and between societies is informative. Within societies, income differences are closely associated with social stratification and hierarchy. However, this is not true of income differences between societies, whether countries or UK states. Kaplan et al. reported that the correlation between mortality and median state income is only -.28 and that when income inequality is controlled it disappears altogether (r = -.06).3 The relationship between per capita gross domestic product and life expectancy is similarly weak (r = .08) among developed countries even when currencies are convened at purchasing power parities. This contrasts sharply with the strong relationship between income and mortality within societies. For instance, Davey Smith et al. showed almost perfectly rank-ordered relationships between mortality and as many as 14 categories of income among Black and White men screened for the Multiple Risk Factor Intervention Trial. The vast international literature on socioeconomic gradients in health provides numerous examples of similar relationships elsewhere.(Smith et al. 2002) The contrast between the strong association between income and health within societies and the weak associations between developed societies suggests that what makes a difference to health is more a matter of people's relative income and status in society than of their absolute material living standards. The declining importance of absolute standards may be marked by the epidemiological transition. The significance of relative income is also suggested by the association between income inequality and population mortality. (Marmot 2003) Lest linking health to social position rather than to absolute material standards seems to provide new scope for explaining health gradients in terms of selective social mobility, it is worth noting that, like previous evidence, the relationship between income distribution and national mortality' rates precludes explanation in terms of social mobility. (Hauck 2002), The primary importance of relative income has profound implications. It suggests that the psychosocial causes of the health gradients within countries are more powerful than the direct physical effects of exposure to poorer material circumstances. Work on the health effects of social hierarchy among both humans and nonhuman primates suggests that in very different material environments low social status is associated with more frequent signs of chronic stress. (Shaw 2000).The internal consistency of the emerging picture would be confirmed if wider income inequalities were accompanied by more pronounced processes of social stratification, differentiation, and discrimination, and so by bigger health differences. In short, is the social hierarchy more hierarchical in societies with bigger income differences The evidence on whether health differences are smaller in countries where income differences are smaller is contradictory: correlations range from .87 to no relation. This may be partly a reflection of whether the social classifications used map closely onto income differences. When health is classified directly by income, the results are unambiguous. But the problem may also reflect the difficulty of comparing income differences between societies. Surveys of household income in different countries have response rates that vary from over 90% to under 60%. What evidence there is suggests that no response occurs disproportionately among the rich and poor, so that low response rates lead to a loss of both tails of the income distribution and so to an art factual narrowing of the reported income differences. Differences in response rates of 30% or 40% can easily lose the difference between the 1.5% of total income received by the poorest 10% of the population in an in egalitarian country and the 3.5% they might receive in a more egalitarian country. Indeed, there is a relationship between response rates and reported income distribution. Analyses of the relationship between income distribution and national mortality rates that fail to consider this are in danger of producing false-negative results. Health care outputs Any assessment of health system outputs faces a bewildering range of potential measures that reflect the controversy around overall system productivity. In terms of assessment against the equity principle of PHC, we focus on two-attainment of equality of access as measured by the proxy of waiting times and attainment of equal geographical quality of health services-the end of what is called 'postcode prescribing'. Waiting lists are the most tangible symptom of inequity within and between the public and private health sectors in England. Eradication of waiting lists has therefore become a policy priority to promote equity and maintain public confidence in a publicly funded health service. The NHS Plan set out annual milestones towards eradication of waits in excess of 3 months for outpatients and 6 months for in-patients by the end of 2005. Substantial progress has been made to reduce waiting lists in both total size and, more importantly, length of waiting time. There has been a reduction from a peak of 1.3 million people on NHS waiting lists in April 2000, to 857,221 in October 2004 . Within this figure, there is a significant reduction in those waiting in excess of 6 months falling from 264,000 in March 2000 to 69,638 in October 2004. The waiting time ceiling target has also reduced from a maximum of 18 months to 9 months . Although there have been examples of outliers from the general levels of improvement across the country, these variations have been usually within a few percentage points of overall attainment. Attention is also now being paid to the, often hidden, issue of waiting times for primary care services. According to the NHS plan, by the year 2004 all patients are expected to have access to GP within 48 hours and a health professional within 24 hours . Whilst at the end of 2001 40% of PCTs were finding it hard to meet these interim targets, particularly the second one , by 2003/2004 the majority (79% and 84%, respectively) of general practices was meeting these key targets . The Minister of Health stated that "97% of patients are now able to see a GP within two days" . The Commission for Health Improvement, however, has criticised PCTs as "technically meeting their target while actually not achieving the underlying goal"; PCTs were not offering any appointments in advance of 48 hours , an example of the dangers of the perverse managerial incentives built into such targets. The importance of this is illustrated by the fact that political attention (with particular embarrassment for the Prime Minister who appeared unaware of the issue) was focused on this particular issue in the last election. Policy objectives for the future focus on waiting for diagnostic tests and times from referral to treatment (including any need for diagnostic tests). Whilst this may be desirable in promoting patient care, it does have the effect of further diverting priorities towards acute care provision and away from chronic care such as in learning disability. Stronger central policy definition and regulation, through for example the development of National Service Frameworks (these are long term strategies for improving specific areas of care, by setting measurable goals and time frames) is aimed at reducing variation in the quality of health service delivery across the country. Although variance still exists, there is evidence through the assessments in clinical governance reviews and annual performance assessment ratings by the Healthcare Commission that quality is improving and variance reducing . Inequality in poor health was largely explained by the factors assessed in the analysis. Importantly, no single explanation emerged; most factors contributed, as anticipated by previous discussions. Nevertheless, some factors had a greater impact than others, notably school qualifications, socioemotional factors, social class at birth, and psychosocial work characteristics for both sexes. Additional influences for men were adult smoking and job insecurity at age 33 years, and for women, housing tenure at age 11, and age at first child, and income at age 23. These key factors occurred at different times of life; socioemotional adjustment and school qualifications, had strong persistent effects, which suggests that differential investment in human resources is a major factor. Given this cumulative model of adult health inequalities, policy implications include reduction of social differences in material circumstances, smoking, and lack of control at work, and strategies to decrease differences in skills and resources acquired early in life (for example, with preschool child development programmes) to influence lifelong health-related circumstances. We need to establish whether these conclusions apply to other health measures. Health outcome inequalities and equality and diversity policies The Labour government has given high priority in its policies to reducing the levels of inequity in health experience alongside an objective of improving general health levels. A recent report monitoring progress on inequalities suggests mixed results in terms of achievement against these policies . On the positive side, progress is reported on child poverty and housing and in some specific disease areas. However, for two key indicators - inequalities by social class in infant mortality and life expectancy have widened. The independent monitoring group also calls attention to need for greater focus on other forms of inequality including by ethnicity. The following explores the details of this. One important proxy measure of population health is average life expectancy at birth. Throughout the 1980s to the present, there was steady increase in life expectancy . However, significant gaps in life expectancy remain, both geographically and between socio-economic and ethnic groups , and - for example, there is a two-fold difference in infant mortality by social class . Generally whilst average population health improves, persistent gaps in health experience between the rich and poor remain and in some cases are even widening and . Health Action Zones were created in 2000-2005 in 26 areas across England particularly challenged by poor health and lower life expectancy - largely in the post-industrial urban areas in the North of England and London. Persistent inequalities were acknowledged in subsequent initiatives such as 'Programme for Action' and 'Spearheads' and 'Communities for Health' launched with the publication of the Public Health White Paper in 2004 . All these initiatives have a common theme-to provide extra resources for community development and cross sector activities, particularly across the Local Government departments such as education, community safety and regeneration, recognising the wider determinant of ill health. However, whilst all these initiatives had been positively received by PCTs and the public health community, the timescales for reversing the trends in life expectancy will require political commitment for many years. One important and persistent area of health inequality has been for minority ethnic groups. Despite many national and local initiatives, poor health inequalities persist . For example, prenatal mortality within communities with Pakistani and Caribbean origins is almost double the national average . Furthermore, recent widespread criticism of 'institutional racism' in some areas of public service, has led the government to launch a new programme to promote diversity and mentorship. Inequalities in infant mortality by father's social class narrowed between 1980 and 1995. However, the first available trend data according to mother's social class, which are arguably more meaningful in this context, suggest a widening between 1986 and 1995. Post-neonatal (1-12month) mortality among the infants of fathers who were unskilled manual workers in 1993-95 was over twice that among those of fathers who were professionals. Infant mortality between 1990 and 1995 was 50% higher among the infants of mothers born in the New Commonwealth (the Indian subcontinent, East Africa, and the Caribbean) than among those of UK-born mothers (100% higher in the case of Pakistani-born mothers). (Dorling 2003). There was also social-class variation within each national group. (Charlton, 2005) Childhood mortality between 1979 and 1993 again showed the picture of overall improvements accompanied by increased inequality. In particular, by 2003-93 the children of unskilled manual workers faced twice the risk of death of all other social classes together. Inequalities are especially striking for accidental death.( Drever, 2003) Conclusion In an increasing number of countries, governments are pursuing inter-sect oral policies to tackle the social determinants of health inequalities. They are looking to the scientific community for evidence to guide the development of these policies. This requires an inter-disciplinary science: one capable of capturing both the dynamics and the health consequences of social inequality. In summary, it can be seen that there is now more apparent interest in inequalities than previously. However, unsurprisingly, the health inequalities are significantly a function of wider forces outside the direct control of the NHS, and raises major challenges for the NHS at different levels in its growing health promotion responsibilities as discussed later. References Charlton J, ed. 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