Intended for healthcare professionals


Doctors can act as advocates on health effects of poverty, says BMA

BMJ 2017; 357 doi: (Published 21 June 2017) Cite this as: BMJ 2017;357:j2976

Re: Doctors can act as advocates on health effects of poverty, says BMA

Doctors are quite right to express concern about the negative effect that inequality can have on physical and mental health, and life expectancy.(1) There is now a vast body of literature on inequality and although the causes of poverty are complex and intertwined, a crucial point to make is that health inequities are amenable to change.(2-9)

We strongly feel that in order to address this fundamental public health area three key measures need to be implemented. Firstly, a new long term public health strategy should be produced that not only focuses on key topics such as healthy eating, sensible drinking and mental health but also seeks to address the ubiquitous issue of inequalities. At a local level the driving force for implementing this strategy should be Directors of Public Health with robust and adequately resourced multidisciplinary departments.(10,11).

Secondly, all new government policies should be reviewed to ensure that they do not have a negative impact on health.(12) Where possible, policies should protect and or promote health. The government should be creating social and physical environments that facilitate healthy options. A national champion will be needed to coordinate and maintain momentum.

The third important priority is that there needs to be a paradigm shift in our thinking away from merely treating ill health and towards promoting positive health. Health promoting environments are needed; these include health promoting hospitals, general practices and workplaces.(13,14) The development of positive health indicators would support policy initiatives and aid monitoring and evaluation. Moreover, they could also be used to encourage the public and professionals to act.(15,16)

Examples of some positive indicators include: percentage of adults who are a healthy weight; percentage of children undertaking the recommended level of exercise per week; and the percentage of homes with a working smoke alarm. At a higher level they can also be developed for example in relation to cycle lanes and various workplace policies.

Doctors and nurses do of course have significant roles to play in addressing inequalities in health. The BMA report correctly highlights roles in relation to: individual patients; commissioning services; and advocacy.(1) Brief case studies are also described including social prescribing services for vulnerable patients.

Finally, the report states that the NHS as a whole, with direction and additional resources, could do more to tackle poverty and thereby saving money in the long term. The health service could provide further support for the people it serves including patients, staff and the local community. It is a major employer and a major purchaser of goods and services: the “health dividend” needs to be seized.(17). We need to have health promoting hospitals.(13,14)

1) BMA. Health at a price: reducing the impact of poverty. Jun 2017.

2) World Health Organization. Declaration of Alma-Ata. Geneva: World Health Organization, 1978.

3) Black, D. Inequalities in Health: Report of a Research Working Group. London, DHSS, 1980.

4) Whitehead, M. The Health Divide: Inequalities in Health in the 1980's. London, Health Education Council, 1987.

5) Department of Health. Independent Inquiry into Inequalities of Health: Report (chairman, Sir Donald Acheson). London, The Stationery Office, 1998.

6) Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002.

7) Marmot M, chair. Fair society, healthy lives (the Marmot review). UCL Institute of Equity, 2010.

8) The Kings Fund. Inequalities in Life Expectancy. London: The Kings Fund, 2015.

9) British Medical Association (2016) Health in all policies: health, austerity and welfare reform. London: British Medical Association, 2016.

10) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013.

11) Watson M and Tilford S. Directors of public health are pivotal in tackling health inequalities BMJ 2016;354:i5013.

12) Watson M C and Lloyd J. Re: Time to put health at the heart of all policy making British Medical Journal Rapid Response 3rd June 2017.

13) Poland B, Green L and Rootman I (eds). Settings for Health Promotion. London: Sage Publications, 2000.

14) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care 2008; 16:177-185.

15) Catford JC. Positive health indicators – towards a new information base for health promotion. Community Medicine. 1983; 5: 125-132.

16) Watson M C and Watson E C. Premature deaths across England. Time to focus on positive health indicators to reduce health inequalities BMJ 2013;347:f4210.

17) Middleton J. Managing public health – health dividends and good corporate citizenship. Int. J. Management Concepts and Philosophy.2010; 4(2), 154-176.

Competing interests: No competing interests

27 June 2017
Michael Craig Watson
Associate Professor of Public Health.
Sue Thompson, Secretary Institute of Health Promotion and Education, Welwyn AL6 0UD, UK.
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA