Child poverty in the UK 2013

Child poverty in the UK remains at a high level and is well documented in the End Child Poverty report and maps published this month. The Marmot review of health inequalities found that that child poverty has a severe impact on children’s health, and called for a strategy to give every child the best start in life.

End Child Poverty calls for Government action from at national, regional and local levels to achieve the target of the Child Poverty Act 2010 to end child poverty by 2020.

There are four dimensions of poverty captured under the Child Poverty Act, each with a target to be met by 2020. They are:
• Relative low income poverty (below 60 per cent median household income)
• Absolute low income poverty (below 60 per cent of median household income held constant at 2010/11 level)
• Persistent low income poverty (below 60 per cent of median household income for three years or longer)
• Material deprivation combined with relative low income (below 70 per cent median household income and suffering from inability to afford essential spending needs)

Inequalities - a lost battle?

The King's Fund have a current Blog entitled Have we lost the battle to improve health inequalities? Gabriel Scally, Associate Fellow of the Institute for Public Policy Research has the opinion that more could and should have been done towards acheiving social health equality.  

                                                                                         The government's key aims to reduce social health inequality were listed in 'Fair Society Healthy Lives' and reviewed in (The Marmot Review Summary) 2002:

Give every child the best start in life.

Create fair employment and good work for all.

Ensure healthy standard of living for all.

Strengthen the role and impact of ill-health prevention.

Create and develop healthy and sustainable places and  communities.

Enable all children, young people & adults to maximise their  capabilities & have control of their lives.

On all counts, there still seems to be a long way to go to.

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Scotland's health inequalities - 50 years on

Audit Scotland's Report out this week acknowledges that over the past 50 years there have been some improvements in Scotland's health inequalities but there is still a very long way to go. It's not surprising that the worst health problems are linked with deprived areas. Deputy Scottish Conservative leader Jackson Carlaw says that people, regardless of their background, have to take responsibility for their own health, but also calls on ministers to do more. See the BBC news item for comments on the results of the report. 

Join Professor Steve Field and others in DH's health inequalities and inclusion webinar on Thursday 7 June 11.30am – 12.30pm.

Map of Europe

A study from the European Health Observatory analyses the complex relationship between health systems, health and wealth.  It considers the latest data on cost pressures on health systems in an unclement economic climate and assesses the economic costs of ill-health in Europe.  The paper also looks at the economic argument for public health interventions and the effectiveness of policies and interventions to reduce health inequalities.  A European survey of access to healthcare for vulnerable groups by Medecins du Monde (MdM) reports data drawn from MdM centres in Brussels, Amsterdam, London, Munich and Nice.  Primary concerns are lack of access to primary healthcare, antenatal care and vaccinations for destitute EU nationals as well as migrants and asylum seekers.

Cancer update

A study from the Cancer Research UK Cancer Survival Group asks how many cancer deaths in England would be avoided if socioeconomic inequalities were eliminated? Based on data covering 1996-2006, the researchers conclude that while avoidable deaths have reduced, the gap between rich and poor remains substantial: "over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups." Latest data from ONS (up to 2009) confirms the persistence in geographic inequalities in survival, with the north-south divide reduced but still in evidence. A more detailed study of socioeconomic inequalities in survival from breast cancer in South West England looks at whether inequalities are present in screening-detected cancer as well as in symptomatic women. The researchers found inequalities with screening detected diagnosis, but in a less marked way. Research on cancer spending amongst primary care organisations in South East England suggests spending was not so much associated with disease burden than activity: "Lower per capita spending on cancer was associated with smaller PCT populations and a higher proportion of deprived areas within them." Finally, a major study from Cancer Research UK examines causes of cancer in the UK in 2010: lifestyle appears to be a major culprit, accounting for over 40% of cancers diagnosed.

Institionalise!

This week the new Institute of Health Equity at UCL was launched. Led by inequalities expert Professor Sir Michael Marmot, the Institute will be funded in part by DH and the BMA. In his first blog post, Marmot expresses some optimism as regards the coalition government's commitment to tackling health inequalities, quoting Don Quixote: "the dogs are barking, Sancho; it is a sign we’re moving."

Deciding to make a difference

As England's public health system is on the brink of enormous change, a timely study of how public health decisions are made comes from a team at Liverpool University. Taking cardiovascular disease as a case study, researchers looked at decision-making by healthcare and public service professionals in an effort to reduce health inequalities. A study in the European Journal of Public Health compares Scotland and Belgium's policies to tackle ethnic inequalities in health, in which Scotland is shown to have played the better game (score: Belgium 1 Scotland 4, the study's authors claim).

Mind the gap: what doctors can do

The BMA has published a guide for doctors on how they can contribute to reducing health inequalities, focusing on a holistic approach to medical practice. A study in Social Science and Medicine examines how far general practitioners (in France) contribute to increasing health inequalities by overestimating the health of patients with lower educational attainment. The researchers found that patients of lower and medium educational level were more at risk of being overestimated in terms of self reported health.

Fair's Fare Issue 23

The latest round up of Fair's Fare blogs: Issue 23 is now available on EPHRU's website

Sharing nicely

There's a small storm brewing over the government's proposed approach to funding allocations as regards inequalities, as HSJ has published details of how this works out in practice. It focuses on how funding allocations are made up and the proportion that is allocated on the basis of health inequalities,which has been cut from 15% to 10% in the 2011/12 allocation. The research was done for Public Health Manchester and was included in its submission to the Health Select Committee's inquiry into Public Health. Other submissions to the Committee have been critical of how far the government is including recommendations from the Marmot Report: the King's Fund and BMA's submissions make similar points. However, the report from Public Health Manchester does make clear in numbers who the winners and losers could be under the new arrangements. A DH spokesman quoted by HSJ rather suggested that perhaps this was just one (not entirely correct) interpretation of funding allocations. In the recent past, both the Audit Commission and the National Audit Office have expressed doubt as to the value for money that old arrangement has offered, arguing for better targetting and clearer evaluation of outcomes. The new design for the health premium, based on incentivisation, seems like a response to this criticism. Whether it works for reducing inequalities is another thing, though.

Tangled web

The connection between income inequality and health and social problems is commonly acknowledged, but the exact nature of that link is much harder to explain. A new report from the Joseph Rowntree Foundation asks the big question: does income inequality cause health and social problems? While its authors find little evidence for an entirely affirmative answer, they do note that some research does show a causal relationship and also that income inequalities might be more harmful beyond a certain threshold (following Wilkinson and Pickett's argument in The Spirit Level). While the UK was somewhat below that threshold in the middle of the last century, since the late 1980s we've been well above it. One of the report's authors, Karen Rowlingson, offers a good summary on the LSE blog.
Japan was once the byword for social equality, but since the market liberalisation of the 1990s, things have changed. A conference paper published in the Journal of Epidemiology and Community Health (JECH) charts the widening gap between rich and poor and the relationship between the social change of the 1990s and health inequalities in the second millennium.
An essay from Clare Bambra, also in JECH, muses on the role of the welfare state as determinant of health. The essay focuses on the public health "puzzle" evidenced in international studies of health inequalities: why do Scandinavian states, with rather more generous welfare provision, not have the smallest health inequalities?

Smoothing things out

Spearhead groups were set up in 2001 to help England's most deprived areas in achieving health inequalities targets. By just over halfway through the programme, it became clear that these targets were not going to be reached and that progress was uneven amongst the Spearhead groups. A report from SDO NIHR looks at the reasons behind the inequalities in results and draws some conclusions on effective ways to tackle inequalities in health, looking in detail at cardiovascular disease, teenage pregnancy and cancer. Unusually, the report's authors used qualitative comparative analysis (QCA), which its authors suggest is better at analysing complex causal patterns, as are found in health inequalities.

Going local

Many avowed solutions to health inequalities lie outside of the sphere of influence of public health professionals. So how can local health departments attempt to address inequalities, asks an article in Health and Social Care in the Community? Its authors suggest that the role of social capital is critical. A team from the Netherlands have also published a study about social capital, looking at its relationship with self-reported health and finding that its positive association with health is especially so for people in urban environments

An uphill struggle

Something of a cri de coeur from Clare Bambra and others is contained in a comparison of the Black, Acheson and Marmot reports. Looking at the content as well as the political context in which the reports were commissioned and published, the article find similarities in theoretical underpinning and in effects, not to mention the uncanny likeness of circumstances for Black and Marmot. And there's a rather melancholy conclusion: "Looking to the future, researchers may improve the likelihood of their research having a wider policy impact by focusing less on describing the problem and more on ways to solve it." An analysis of the UK approach between 1997 and 2010 from a Dutch academic is similarly bleak.

Scoffing at QOF?

According to research commissioned by NIHR, the GP pay-for-performance scheme, the Quality Outcomes Framework (QOF) has had minimal impact on public health in deprived areas. As well as milling the data (HES statistics, spearhead status etc.), the team from the King's Fund and the London School of Hygiene and Tropical Medicine conducted interviews with PCT and general practice staff. The gap in performance between least deprived and most deprived practices has decreased since the implementation of QOF, but differences were already small. It should be noted that QOF was never designed to address public health or inequalities issues: the report's main criticisms are reserved for the QOF system itself, which does not incentivise health improvement or public health activities, so much as efficient management of known/existing problems. The content of the 2012/13 QOF is currently being considered.

Not really news

... especially not good news...The National Audit Office's report, Tackling inequalities in life expectancy in areas with the worst health and deprivation, takes a long, hard look at DH's achievements as regards inequalities. And the verdict? A good effort, but not exactly value for money.
"The Department of Health has made a concerted effort to tackle a very difficult and long-standing problem. However, it was slow to take action and health inequalities were not a top priority for the NHS until 2006. We recognize that this is a very complicated issue and that it took time to develop an evidence base. However, the best, cost-effective interventions have been identified and now must be employed on a larger scale in order to have a greater impact and improve value for money.
"The Department should target its efforts on the most deprived areas of the country and develop costed proposals to maintain or increase investment in preventative interventions to tackle the conditions which lead to health inequalities."
Amyas Morse, head of the National Audit Office, 2 July 2010.

Health Policy Insight casts a wise look back to Julian Tudor Hart's inverse care law.

More about health budgets

Two recent articles in the BMJ argue that it’s not just about ringfencing health budgets: social welfare and the health of the nation are far more entwined than that. Joan Benach and others look at the international situation, while David Stuckler and colleagues examine the UK perspective in more detail.
Age UK (the name for the merger between Age Concern and Help the Aged) argues that the Autumn spending review should include ringfencing of social care budgets, too. The King’s Fund’s John Appleby also notes ominously that the real extent of cuts will only be made clear in the Autumn spending review and looks at the ripple effect for health of cuts and the Office for Budget Responsibility’s prediction of slower economic growth.

Working out what works

It usually appears that while it's relatively easy to identify health inequalities, finding robust evidence for what works in tackling those inequalities is rather more challenging. Some recently published articles tend to uphold that assumption. A UK-based team offers a systematic review of interventions and at a more theoretical or policy level, the Marmot review team publish an account of the use of rapid review techniques to develop policy proposals. Meanwhile, at the coalface, another article reflects bleakly on the effectiveness of partnership working and community engagement.

Doctors mind the gap

A policy statement from the Royal College of Physicians sets out the organisation's vision for tackling health inequalities. The result of a series of dialogues over the past six months, the report considers options for change. As well as advocating an emphasis on prevention rather than treatment and considering how doctors engage with and empower patients, the policy statement also acknowledges a need for public health and social aspects of medicine to be better taught.