Inequalities in 2020: time for a health strategy that unites the country.
Peter English is right to stress the importance of tackling the ubiquitous issue of inequalities and to highlight interventions that could make a significant improvement to the country’s health.(1) Over the last 50 years a wealth of evidence has accumulated linking deprivation with poor health and the excellent Lancet study adds further weight to this research.(2-11)
The study found that although premature mortality reduced during the study period (2003-2018), the social inequalities persisted.(2) In relation to children under 10, if everyone had the same life chances as the best-off they calculate that there could have been 22,000 fewer deaths. Overall, they estimated that one in three premature deaths were attributable to socioeconomic inequality, thus making it a crucial public health challenge.
Doctors potentially have considerable roles to play in reducing the impact of poverty. A recent BMA report correctly highlights roles in relation to: individual patients; commissioning services; and advocacy.(11) As trusted and knowledgeable members of society, many doctors could have stronger voices in advocating for the health needs of their patients and local communities.
Health Visitors also have major roles to play in reducing inequalities especially in children’s early years.(12) They focus on health promotion in early years and lead on the healthy child programme (0-5years) concentrating on 6 high impact areas which the Institute of Health Visiting has called to be increased to 15 to include immunisation.(13) However, following the end of the government’s Health Visitor Implementation Plan in 2015 the numbers of entrants for Health Visitor training has reduced from 2787 in 2013-14 to 448 in 2017-18.(14-16)
There are many barriers to doctors, health visitors and other nurses being involved in tackling inequalities and promoting health and a major issue is the staffing crisis. If the vacancies are filled then hard-pressed staff will have time to fulfil their roles in promoting health.(16-19)
The Institute of Health Promotion and Education have previously called for a comprehensive health strategy that would help to minimize disparities and unite the country.(20) In general, we do not feel that one off interventions should be instigated as these may simply get people to change their behaviour with no real improvements in health.
A positive health strategy is needed that creates a culture that supports health and empowers individuals and communities.(20) In order for the strategy to be successful we need:
1. a focus more on population health rather than individual lifestyle;
2. funding that is adequate for the significant tasks;
3. firm political commitment at a national level.
In the past there has been too much focus on individuals. We need a paradigm shift in our thinking away from merely treating ill health and towards promoting positive health. The new strategy needs to encourage health promoting environments; these include health promoting hospitals, general practices and workplaces.(21-23)
In the last decade we have consistently argued for an increase in public health funding.(24-32) We strongly believe that more investment is urgently needed to cope with our current and future public health needs. At a local level it is now time for a multi-year funding settlement so that directors of public health and their teams can address urgent priorities as well as adequately planning for the future. With sufficient resources directors of public health will be able to drive forward a new health strategy at a local level.
At a national level we await the production of a new national public health strategy.(20, 33) It is urgently needed to tackle important issues including: accidents, alcohol misuse, mental health, obesity, and oral health, linked by the underlying problem of inequality. With strong Government support, we believe an ambitious and evidence-based strategy would improve people’s health and wellbeing, tackle inequalities and relieve pressure on our overloaded NHS.
1) Iacobucci G. Public health priorities for 2020: five minutes with…Peter English. BMJ 2020;368:m31
2) Lewer D, Jayatunga W, Aldridge RW, et al. Premature mortality attributable to socioeconomic inequality: an observational study of 2.5 million deaths in England between 2003 and 2018. Lancet Public Health 2019. 10.1016/S2468-2667(19)30219-1.
3) World Health Organization. Declaration of Alma-Ata. Geneva: World Health Organization, 1978.
4) Black, D. Inequalities in Health: Report of a Research Working Group. London, DHSS, 1980.
5) Whitehead, M. The Health Divide: Inequalities in Health in the 1980's. London, Health Education Council, 1987.
6) Department of Health. Independent Inquiry into Inequalities of Health: Report (chairman, Sir Donald Acheson). London, The Stationery Office, 1998.
7) Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002.
8) Marmot M, chair. Fair society, healthy lives (the Marmot review). UCL Institute of Equity, 2010.
9) The Kings Fund. Inequalities in Life Expectancy. London: The Kings Fund, 2015.
10) British Medical Association. Health in all policies: health, austerity and welfare reform. London: British Medical Association, 2016.
11) British Medical Association. Health at a price: reducing the impact of poverty, 2017.
12) Local Government Association. Health visiting: giving children the best start in life. London: Local Government Association, 2019.
13) The Institute of Health Visiting. Health Visiting in England a Vision for the Future. London: The Institute of Health Visiting, 2019.
14) Department of Health. Health Visitor Implementation Plan: A Call to Action. London: Department of Health, 2011.
15) NHS England. Interim NHS People Plan. 2019
16) Health Visitor Training: Department of Health and Social Care Written Questions. Answered March 2019.
17) Watson M C and Forshaw M. Tackling the Crisis in General Practice. Prioritising prevention and health promotion. BMJ 2016;352:i1333. https://www.bmj.com/content/352/bmj.i1333
18) Watson M C and Lloyd J. Pressure on general practice in England. Time to put GPs first by investing in general practice. BMJ 2019;365:l4158
19) Watson M C and Thompson S. Nursing crisis: Missed opportunities in promoting the health of the country. British Medical Journal Rapid Response, 12 December 2019. https://www.bmj.com/content/367/bmj.l6664/rr
20) Watson M C and Lloyd J. The need for a health strategy that unites the country. British Medical Journal rapid response, 27 July 2019.
21) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.
22) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185. https://pdfs.semanticscholar.org/c1b6/3555f6b033effdc0062235adb7bab3de43...
23) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84. https://www.tandfonline.com/doi/abs/10.1080/14635240.2017.1415765
24) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013 http://www.bmj.com/content/346/bmj.f4242/rr/652995
25) Watson M C and Lloyd J. Raiding the public health budget. Action is needed to tackle current public health threats BMJ 2014;348:g2721
26) Watson M C and Lloyd J, 2016. Need for increased investment in public health BMJ 2016;352:i761.
27) Watson M C and Thompson S. Re: Government must not shy away from bold action on public health, says MP. British Medical Journal Rapid Response, 25th November 2016.
28) Watson M and Tilford S. Re: Government’s response to inquiry on public health raises fears of more cuts. There should be investment – not cuts. British Medical Journal Rapid Response 10th January 2017. http://www.bmj.com/content/355/bmj.i6853/rr-1
29) Watson M and Tilford S. RE: Next government must tackle public health “ticking time bomb,” says BMA. British Medical Journal Rapid Response, 15 May 2017
30) Watson M C and Lloyd J. RE: Spending on public health cut as councils look to save money. British Medical Journal Rapid Response, 14 July 2017.
31) Watson M C and Thompson S, 2018. Government must get serious about prevention. BMJ 2018;360:k1279.
32) Watson M C and Cheater S. Lessons from history – public health successes. British Medical Journal Rapid Response, 09 September 2018.
33) Department of Health and Social Care. Advancing our health: prevention in the 2020s—consultation document. Jul 2019.
Competing interests: No competing interests