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Rapid Responses: Rapid Responses published:
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Regional inequalites and cancer
- Michael V Williams (7 July 2009)
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Reducing the gap
- Evan L Lloyd (9 July 2009)
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Do we mind the gap?
- Angela M Jones (15 July 2009)
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Rurality and health deprivation
- A Gordon Baird (30 July 2009)
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Michael V Williams, consultant clinical oncologist Oncology Centre, Box 193, Addenbrooke’s Hospital, Cambridge University Hospital NHS Trust, Hills Roa
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Hawkes draws attention to the heath impact of the widening deprivation gap and to stark regional differences in income1. Deprivation is associated with increased cancer incidence and worse outcomes2. For lung cancer, deprivation predicts increased incidence and a reduced likehood of receiving any treatment.3 A recent national audit of radiotherapy services by region showed that in the deprived regions of Yorkshire and Humber and the North East only 25-28% of cancer patients received radiotherapy4. By contrast, in the three regions of the South East access to radiotherapy (the proportion of cancer patients treated) was 49% and consistent with international norms. This two-fold difference is striking and across English regions reduced access to radiotherapy was strongly correlated (r= -0.820) with increasing deprivation.4 Further research is needed to investigate both the hypothesis that patients in deprived areas present late with advanced disease and comorbidity2,4 and secondly the proposal that access can be improved by raising patient awareness and by earlier diagnosis5. The links between deprivation and reduced cancer survival are complex2 and Hawkes points out that the problems of inequality have not been solved by providing access to a GP and to universally available care of a consistent standard. 1 However, lung cancer patients, whose first hospital attendance was at a radiotherapy centre were more likely to receive active treatment and there was evidence of longer survival.3 This suggests that cancer pathways and barriers to specialist care are critical.3,5 Improved outcomes will require a clear focus on rapid access for all patients to curative first line treatments, particularly surgery and radiotherapy, both of which are effective and cost effective.6 It seems that timely access to an oncologist is an important determinant of outcome. Michael Williams consultant clinical oncologist Oncology Centre, Box 193, Addenbrooke’s Hospital, Cambridge University Hospital NHS Trust, Hills Road, Cambridge CB2 0QQ michael.williams@addenbrookes.nhs.uk Competing interests: None declared 1. Hawkes N. Mind the gap. BMJ 2009; 338: b2604 2. Munro AJ. Deprivation and survival in patients with cancer: we know so much, but do so little. Lancet Oncol 2005; 6: 912-3. 3. Jack RH, Gulliford MC, Ferguson J, Moller H. Geographical inequalities in j lung cancer management and survival in South East England: eveidence of variation in access to onology services? Br J Cancer 2003; 88: 1025-31 4. Williams M V, Drinkwater KJ Geographical variation in radiotherapy services across the UK in 2007 and the impact of deprivation. Clin Oncol (2009) in press, doi:10.1016/j.clon.2009.05.006 5. Department of Health. Cancer Reform Strategy. Department of Health, London, 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081006. 6. Barton MB, Gebski V, Manderson C, Langlands AO. Radiation therapy: are we getting value for money? Clin Oncol 1995; 7: 287-92. Competing interests: None declared |
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Evan L Lloyd, retired 72 Belgrave road, Edinburgh EH126NQ
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Dear Sir The article by Nigel Hawkes [1] is very timely. He emphasises the fact that inequalities in health have widened in line with the increasing inequality in absolute income. Hawkes quotes the huge disparity in gross domestic product (GDP) in the UK (54% of the average in the most deprived areas to 444% in the most prosperous), compared with 71% to 154% in Denmark and 73% to 125% in the Netherlands. It is also interesting that 3 of the countries with the widest disparity in income (USA, UK, and Portugal) also have the widest level of inequality of health. By contrast countries with the smallest disparity in levels of income (Nordic countries and Japan) also have the smallest difference in health inequalities. One problem exacerbating the situation in the UK is the fact that the people living in the most deprived areas also live in the poorest quality housing, which is badly insulated among other defects. This means that the costs of heating the house, even inadequately, requires a disproportionate percentage of what is an already very low income. Add to this the fact that poor insulation leads to problems with condensation and the development of mould, which in turn can rot fabrics and carpets leading to the additional expense of necessary replacement. I would suggest that fuel poverty should be redefined as poverty produced by trying to heat poor quality housing Add this to the health problems which result from cold, damp, and the presence of mould and it should be no wonder that the health status is poor. Is this what is meant by ill-health being due to lifestyle? There is however one measure which has the potential to make a significant change. Easterhouse, is a very deprived area of Glasgow with major problems with health, poverty and very poor quality housing. In one subsection, Easthall, thanks to the determined efforts of the residents, 2 blocks of flats (36 flats) were refurbished to a very high standard. The effects on health were remarkable [2]. The main factor studied was blood pressure (BP), and this fell from a mean of 142/85 to 122/73. In one other study [3] it was shown that controlling the systolic BP to 140 mmHg reduces the incidence of coronary heart disease (CHD) by 25-35% and of stroke by 28-44%. Another study [4] showed that lowering the diastolic BP by 5 mmHg reduces the incidence of CHD by 21% and stroke by 34%. Finally a population study [5] showed that if the BP in men could be reduced from 136/88 to 129/81 the standardised mortality ratio (SMR) changed from 136 to 61, and in females a change in BP from 137/84 to 129/77 would reduce the SMR from 147 to 50. All the changes in BP quoted are smaller than those achieved in the Easthall refurbished housing, and this effect on BP was produced without the use of medication. In one particular resident the incidence and severity of cardiac incidents fell dramatically. There were also marked reductions in the incidence of respiratory disease, and 3 people with severe asthma were able to stop all medications. Patients with arthritis were able to make major reductions in their medication. An important factor in improving health, seems to be reducing the temperature differential between the rooms rather then the absolute temperatures. There are possible secondary health benefits from the change in thermal staus, for example previously young children missed vaccination because of repeated colds and were therefore at risk from a number of preventable conditions, and older children were losing time off school. Before the refurbishment, many families could afford to heat only one room and the whole family tended to eat and live in that room, putting great stress on family members with increased risk of family or individual breakdown or mental disorders. With the improved heating people could use all the rooms. Children could study, warmly, away from the distraction of the television in the living room, with possible implications for education, future employment, income and consequently health. All these factors should reduce demands on scarce NHS resources. There were also major financial benefits. Energy audits of the original flats in 1990 showed that in winter people would have to spend £60/week to achieve the recommended healthy temperatures throughout, and to avoid the risk of condensation dampness. Because of money problems only one room was usually heated, and the poorest families, and the unemployed, had up to £35/week deducted from social security benefits to cover heating costs. However the refurbished flats could be kept comfortably warm throughout for about £7/week, and this also provided plenty of hot water. The absence of damp and mould produced a further saving in not having to replace carpets and furniture destroyed by mould growth. The refurbishment seems to have the potential to marginally decrease the financial disparity between the very poor and the very wealthy, and also to decrease the health inequalities. In the current financial situation, this seems a golden opportunity. Large numbers of unemployed building workers could be employed in refurbishing Scotland’s, and the UK’s, large stock of poor quality housing. This could have the combined effect of reducing unemployment, increasing income from taxation, reducing the financial load on the NHS, and improving the health, and financial situation, of the very poor. It could also have a major impact on carbon emissions, and therefore climate change. One caveat is that refurbishment MUST be thermal with adequate insulation of walls and roofs, and efficient central heating as a minimum standard. Too many so-called refurbishments have been purely cosmetic with no thermal improvement. I have personally seen this happen even in Easthall very near the refurbished houses, which showed such a potential for change. References 1. Hawkes N. Mind the gap. Britain is a profoundly unequal country, and there’s not much that health care can do about that. BMJ 2009;338:b2604. 2. Lloyd EL, McCormack, McKeever M, Syme M. The effect of improving the thermal quality of cold hosing on blood pressure and general health: a research note. J Epidemiol. CommunityHealth 2008;62:793-797. 3. He FJ, MacGregor GA. Cost of poor blood pressure control in the UK; 62,000 unnecessary deaths per year. J Hum Hypertens 2006; 17(7): 455 -7. 4. Law M, Waki N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess 2003; 7(31): 1-94. 5. Tunstall-Pedoe H, Smith WCS, Crombie IK, et al. Coronary risk factors and lifestyle variation across Scotland: results from the Scottish Heart Health Study. Scott Med J . 1989; 34: 556-560. Competing interests: None declared |
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Angela M Jones, Freelance GP OX14 4PD
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Nigel Hawkes’ Observation piece (BMJ 4 July 2009) outlines elegantly the issue of the inequalities in health which exist in the UK today and which reflect inequities within our society. I must take issue with him on his statement in the subtitle: “Britain is a profoundly unequal country, and there’s not much that health care can do about that”. I have to disagree with the second half of this assertion and in the next paragraphs, I will explain why. Hawkes seems to take as his thesis that health care in the UK, in the form of the NHS, has achieved its ultimate goal: that we have reached a situation where everyone has access to a GP and that health care of a consistent standard is universally available. I would contend that the reality is far from this ideal. Inequities in access to general practitioners are well documented – indeed the issue of ‘under-doctored areas’ has been the subject of concern and policy initiatives for years. It is not surprising that the areas with too few GPs per head of population coincide remarkably accurately with areas of socio-economic deprivation – a fact that reflects, among other factors, the failure of the system to provide the kind of working conditions and joined-up support services that would attract GPs to work there. Less well-documented is the fact that certain groups of the population find it difficult to register with a GP at all. That these groups include people who exhibit challenging behaviour, who move frequently with their work, who are homeless or vulnerably housed or gypsies, travellers, migrants, refugees or asylum seekers will come as no surprise to anyone who thinks about the situation realistically. GPs have the discretion to register anyone for primary care whom they believe to be eligible, yet it has become common practice to require identification papers, proof of address or other documentation in order to register. Where the impetus for introducing what is in effect a barrier to services has come from is unclear – the Department of Health have not issued guidance to this effect, so it is either coming from PCTs or from the practices themselves. Wherever it is coming from, the effect is the same – people with the greatest health inequities are often finding it the hardest to obtain access to comprehensive primary care. Availability of a consistent standard of health care is also far from a reality. There is more to this than GP access. Obtaining access to health care has been said to depend on two factors: candidacy and permeability. The person must feel that they are a candidate for a certain health intervention, and the health professional to whom they present must concur. When one considers this concept of candidacy, there are obvious problems for all sorts of groups in terms of their consideration of themselves as candidates for treatment, and arguably still more when it comes to the verdict of the system as to their candidacy. We have NICE guidance for some treatments, which in theory should sort out some of the candidacy issues; however, the problem of NICE non- compliance is one that is yet to be addressed with any real vigour. And then there are all the areas for which NICE guidance is not available. And overarching all of this is the huge issue of discriminatory attitudes and stigmatisation experienced by certain groups of patients, which has yet to be tackled by the ‘diversity’ machine within the NHS. People with addictions, people who behave oddly or challengingly, people who do not speak good enough English, people with intellectual disabilities, people who sleep rough or who smell or who are old and possibly confused, suffer discriminatory behaviour with treatment delayed or denied within our system to an extent that is shameful and largely unacknowledged. As a fellow professional I might find these failings understandable in the context of the lack of attention to support of and training for staff around these issues, compounded with the continuous pressure of the media discourse around demographic change, the aging society, migration and now the economic downturn. It is hardly surprising that these groups, which represent people who are already subject to inequity and poorer health, often experience the less satisfactory end of the Gaussian curve of ‘consistency of care’ that exists in our NHS and it represents a failure that should be addressed within the current review of health inequalities. Furthermore, the system needs to be “permeable” i.e. the person should not have to expend excessive energy in navigating the health system in order to obtain the care. Permeability has never been a strong point of the NHS. Barriers to access have been, and remain, an essential tool of rationing, in the absence of any overt rationing debate. As a new approach to improving access, the Government invented the Choice Agenda, but who is getting the choice? Is it those experiencing the greatest health and social inequities? Not usually. In fact, the very instruments of choice – such as ‘Choose and Book’ whereby you can opt to go to a hospital many miles away for your treatment if you wish, or have the means of transport, or the provision of Walk in Centres which are designed to deal with a small range of minor illnesses yet are too-often touted as an access solution for hard to reach groups, or the ubiquitous automated hospital switchboards which have to be negotiated in order to make a hospital appointment, but which all too frequently keep one hanging on for many minutes, only to lose the call at the vital moment – reduce permeability and thus mitigate against the most vulnerable in our society, the elderly, those reliant on public transport, those with complex and multiple needs, those without a landline phone. And what are we as health professionals doing about all of this? Do we challenge our colleagues when we witness discriminatory language or practice? Do we draw the negative impacts of the implementation of new appointment systems or other changes to the attention of the relevant executives? Do we insist on a significant event analysis whenever a vulnerable patient has received less than satisfactory treatment? Do we avoid seeing the patient with the mental health problem or who does not speak English, even when they are next in the queue? Do we provide good role models to the students within our institutions? Are we advocates for our patients or have we become too preoccupied with, or cowed by, the pervasive target culture within which we now work? Nigel Hawkes is right in that health inequalities are largely a result of the other inequalities in our society. As health professionals, we could be out there demanding, for instance, fairer benefit systems, a decent old age pension for all, without resort to means tested top ups, more cohesive communities and a better, more sustainable environment and transport system, in that these factors will improve general health and well-being. Additionally, we could be insisting on improved provision of welfare, social, housing and employment services within our organisations so that the ‘social admission’ or presentation becomes an opportunity instead of a nuisance. But we should also be setting our own house in order, and ensuring that equitable access and consistency of care can be guaranteed in our NHS. It is inexcusable to allow inequities in care to exacerbate pre- existing inequities in society and we should not stand by and allow this to continue. Unless we all fight for fairness within our own small corner of the system, the situation for the least advantaged risks becoming even worse. The question is: Do we mind the gap? And if we do, what are we prepared to do about it? Competing interests: AJ is Chair of the Health Inequalities Standing Group of the Royal College of General Practitioners. She is a partner in the Inclusive Health consultancy, run on socisl enterprise prinnciples.The views expressed in this article are her own . |
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A Gordon Baird, GP Sandhead Surgery,Sandhead, Wigtownshire DG9 9DP
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Hawkes quite correctly points out the importance of recognising health inequalities. (1) While socio-economic issues are well recognised, the effect of being rural or remote on health care outcomes is often overlooked in the United Kingdom. Remoteness from highly specialised care compounds the economic difficulties of accessing care . Survival from cancer (and mortality from other diseases) is poorer in rural areas.(2) In Scotland, access to specialist care for rural cancer patients is reduced with inpatient admissions significantly less after one hour’s travelling and increasing to a threefold effect with three hour’s travelling. (3) Many patients bypass their nearest specialist unit to a more distant hospital because of political or managerial decisions over care pathways that involve specific managed clinical networks. Being remote and rural has very significant effects on health and well-being, not always in a positive way. The rural socio-economically deprived suffer disproportionately, but in the UK largely unrecognised. This is freely acknowledged in other countries.(4) The increasing evidence of rural health care inequalities within the UK lies uneasily with a policy of increasing centralisation in primary and secondary care. 1.Hawkes N. Mind the gap. BMJ 2009; 338 2. Campbell NC, Elliott AM, Sharp L et al: Rural factors and survival from cancer: Analysis of Scottish cancer registrations. British Journal of Cancer 2000; 82(11): 1863-1866. (3) Baird G, Flynn R, Baxter G, Donnelly M, Lawrence J. Travel time and cancer care: an example of the inverse care law? Rural and Remote Health 8 (online), 2008: 1003. (4) Sabesan S, Piliouras P. Disparity in cancer survival between urban and rural patients – how can clinicians help reduce it? Rural and Remote Health 9 (online), 2009: 1146. Competing interests: Ex Chair of the Rural Practice Standing Group of the RCGP |
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