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Why the NHS Plan needs to be far more ambitious to tackle inequality

Inequality is a national disgrace that affects the health and wellbeing of us all, especially our children. Bolder action is needed to tackle it.

Image: Homeless person sleeping outside Fortnum & Mason, London, in freezing temperatures, 2018. Credit: Velar Grant/Zuma Wire/PA Images, all rights reserved.

‘In the bleak mid-winter’ - never has the opening line in the much-loved Christmas carol seemed more appropriate than now as 2019 gets underway.

Bleak for the poverty, inequality, hopelessness and despair affecting too many people in this, one of the richest countries in the developed world. Why is this the case – and what’s to be done about it – are two questions that politicians need to answer. 

14 million people (22% of the population) live in the UK on incomes below the poverty line after housing costs, many trying to survive without income in the chaos of implementing Universal Benefits. Demands for food from the Trussell and other food banks is soaring, with many former middle-income families now seeking help.

The impact on children is especially worrying with 4.5 million – nearly one in three – living in poverty. And the number is rising. Poverty is especially prevalent in families with children with a disability, the stress of which unsurprisingly leads to the breakdown of countless families.

The number of homeless children and those needing protection is soaring, with many authorities failing to intervene until complex cases reach crisis point. Over 47,000 children (65% of all looked after children) are in 63% of councils that, say Ofsted, are inadequate or require improvement. 

The UK is one of the most unequal of western European countries; this is shameful in a nation which invented the Welfare State and the NHS.

Worse still, these inequalities are increasing. Between 1979 and 2012, only a tenth of overall UK income growth went to the poorer half of the population, and the bottom third gained almost nothing. The richest 10% took almost 40% of the total and15% of adults owe more than they own. 

Inequalities of wealth are even larger than those of income. 44% of the UK’s wealth is owned by 10% of the population, while the richest 1% are estimated to own 14% of the nation’s wealth.

Inequalities in expectation and education compound the difficulties.

These inequalities inevitably build a politics and a society riven by division that is compounded by the disconnection between the political classes making policies and the realities of the lives of real people who are affected by them.. Take, for example, the plight of the desperate 9-year old girl in Torbay who begged a local charity for any work to support her recently widowed father who had lost his job. The charity invited Theresa May and Esther McVey, the Work and Pensions Secretary to visit her. She said: "I want them to see the reality of what Universal Credit is doing, to see the look of 'no hope' in people's eyes when they come asking for food."

Inequality kills 

Inequalities lead to poor health, which threaten the health and wealth of everyone. In the poorest areas of the UK, people live on average ten years less than those living in the richest areas. This is not surprising when poor people are bombarded with pressures to eat cheap fast food, are unable to afford to meet government healthy eating recommendations and without time or healthy environments to take exercise in.

Children again are particularly affected, and poverty should be seen as an ‘adverse childhood experience’ with negative impacts on development, behaviour and long term wellbeing and longevity.

Inequality affects social cohesion.

Inequality means community life is weaker; austerity undermines civil institutions which support links between people, such as access to libraries, social care, youth work and community development. Countries with big income differences tend to have less social mobility and more segregation. For example, in the UK only 4% of doctors come from disadvantaged families 

People facing poverty have less control over their lives – control is one of the most important factors enabling people to thrive physically and emotionally. Their ability to care for themselves or for the welfare of others is eroded. Drugs, alcohol and obesity become more common, threatening the health not only of the individual but also of the whole of society. Inequality is a prescription for misery and wasted lives.

The NHS and Local Authorities can make a difference

We have an NHS that ensures that everyone can get good care when they are ill, but it is reactive and not proactive in helping to tackle inequalities. Is the NHS becoming a fig leaf for the deep-seated unfairness of our society?

Although the key lies in national or even supra-national economic and political changes, the NHS has a responsibility to rectify or at least mitigate the health consequences locally in our alienated societies. How might it do so? 

A good start would be for the NHS to address such inequalities as an employer, leading by example. Recent pay awards suggest that this is the intended direction.

Another fundamental evidence-based change that would help shift the balance would be for the NHS, with Local Authorities, to better connect with the communities that they serve by supporting health communities to build increased social capital. It is also clear that the state has a significant responsibility to act on the social determinants of health that make it more difficult for communities to get engaged: better working conditions, better pay, improved housing.

Sir Michael Marmot, Britain’s leading expert in health inequalities, is clear that stronger communities are key to tackling the problem. He shows that the state can intervene to create and deepen social networks and capital. Ideally, intervention needs to be local activity in a national context.

We know that health is a social process, not just an individual one. Our links with other people has a big impact on our health. For instance, there is a 50% higher likelihood of survival for people with stronger social relationships. This effect size is comparable with stopping smoking, alcohol, reducing weight and physical activity. It is consistent across age, sex and cause of death.

We know that improving contacts between people increases confidence and this encourages people to take more control over their lives. Taking more control is a key factor in maintaining and improving our mental and physical health. 

Social prescribing is a welcome development in the NHS. It signposts and supports individuals to make use of existing and created community assets, although many of these are being cut as a result of austerity, threatening the sustainability of the approach. It could be the Trojan horse for creating a community infrastructure that supports a healthier physical and social environment for everyone.

Community development – the next step

Community development builds on and goes beyond social prescribing. It enables people and communities to work together to identify their own needs and actions, develop their confidence, skills and knowledge, to challenge unequal power relationships, to take collective action (working with the statutory sector) using their strengths and resources, and to promote social justice, equality and inclusion.

Where such community development has been encouraged it has been shown that statutory services become more responsive, community resilience is enhanced, health inequalities are addressed, and health behaviour is improved.

In Lewisham, public health, working with community development, improved activity levels, smoking and diet – and shifted people’s use of GP services towards primary and secondary prevention. Salford Dadz has transformed the lives of men and their children.

There is also good economic evidence that money is saved for the benefit of everyone. For every £1 invested a Clinical Commissioning Group would get about £4 back. Some studies even suggest a return of 15:1 implying that community-centred approaches such as community development can, through reductions in A&E attendance, planned and unplanned hospital admissions and outpatient attendances release savings of 7 % for Clinical Commissioning Groups. That is an average saving of around £21m per Clinical Commissioning Group. Why doesn’t the Treasury understand the economic implications of building thriving communities? The Healthy New Town approach, supported by Treasury, has shied away from recommending that communities take back more control. 

Community Development through trained community development workers helps support participatory democracy because it mobilises communities to collaborate with each other and with the statutory and voluntary sectors to make change. By this collective shared decision-making, communities can begin to take back control and improve their health.

Part of the infrastructure for Community Development has to be good local data. The Human Early Learning Partnership model in Canada ‘maps’ children’s lives from routine data by locality - inputs, outputs and outcomes across health, education, social care, youth justice and poverty. These data are used to inform advocacy for children’s needs, and to recommend changes to policies and funding. If we had similar ‘mapping’ databases here, it would be an excellent substrate for community development.

The NHS has made significant strides over the years. Indeed, these ideas are written large over the NHS’s Five-Year Plan and will hopefully be written even larger in its Ten-Year Plan.

Do we have the political will?

Increasing inequalities in wealth are creating increasing inequalities in health. This will harm everyone in the long run but particularly those least well off. Our children, who can least protect themselves, will suffer most. That is because they will endure, in many cases, a lifetime of inequalities with all its threats to health.

Community development helps to mitigate such health inequalities by enabling communities to take back control. It is not a substitute for real economic change that demands political will to address. 

The NHS now needs to work with Local Authorities to deliver community development as ‘business as usual’ in out of hospital care. Extensive evidence suggests that this would result in significant improvement in health, happiness and reduced costs. ‘It takes a whole village to develop a thriving community’ should be the mantra, in other words, doing so should be everybody’s business.

This ‘paradigm shift’ now needs to become part of a new civic and economic settlement that challenges the causes and the results of inequality and moves towards a system that is not only more socially just but fair and compassionate for the most vulnerable. Effective leadership will be key.

The NHS Plan has started the conversation, but we need to be more ambitious still. We need a commitment to community-centred approaches to help tackle health inequalities with a better co-ordinated plan linking a broad range of agencies and departments nationally and locally if we are to make a serious impact on poverty and its antecedents in childhood.

As a nation, do we have the care and compassion and above all, the political will that is necessary to achieve this? We did in 1948, when we created the NHS. Let’s do it again.

About the authors

Professor Sir Al Aynsley-Green Kt. Former Director of Clinical R&D, Great Ormond Street Hospital for Children, London, first National Clinical Director for Children, Department of Health, and first Children’s Commissioner for England.

Dr Brian Fisher is the chair of the New NHS Alliance.

Dr Michael Dixon is the Chair of the College of Medicine.


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