Public health prose

The month of May, with two bank holidays and some time to breathe. The first, near May Day (or International Workers' Day), celebrated the international labour movement and its achievements for working people. The latter is the Spring Bank Holiday. This year we also have elections on 22 May. All 32 London boroughs will elect their councilors as will some metropolitan councils. We can choose our Members of the European Parliament and some of our most deprived boroughs (Hackney, Newham, Tower Hamlets and Lewisham) also elect mayors. How will these elections unfold? How will the national and the European influence the local? How will issues of economic austerity, immigration, unemployment, housing shortages and the pressure on public finances play out?

On 31 May, we have World No Tobacco Day.¹ This year the call is to raise taxes on tobacco. Heavy taxation is “the single most important opportunity for national governments worldwide to curb non communicable diseases”.² It will particularly reduce smoking in low-income groups and prevent young people from starting.¹ This prose is a short piece on health inequalities: just snatching an additional quick puff on this topic as this important issue runs through all these articles.

Social class or socioeconomic differentials in health status are stark. The difference in male life expectancy between the least and most affluent areas in England is 8.1 years. The difference in the amount of that life spent in good health (healthy life expectancy) is even greater, at over 14.7 years.³ Around London, we see a male life expectancy of 81.7 in Harrow and 77.2 in Islington and Barking and Dagenham. The widest difference within one borough is in Westminster: 14.0 years.⁴ The gap is widening within most local authority areas of England.⁵ Sir Donald Acheson, the former Chief Medical Officer, wrote: “Inequalities in health exist, whether measured in terms of mortality, life expectancy or health status; whether categorised by socioeconomic measures or by ethnic group or gender.”⁶ Among men, smoking is responsible for over half the excess risk of premature death between the social classes.⁷ Some black, Asian and minority ethnic groups – e.g. black Caribbean men and women, Bangladeshi men and Irish women – have particularly high smoking rates,⁸ and more than 60% of people with schizophrenia smoke.⁹ We know that social determinants such as housing, income, environment have a major impact on health, particularly in the long term.

Addressing these inequalities is a major challenge that eminent figures and organisations have focused their efforts on over many years. I will pick on just two approaches and then return to theme of engaging communities, in line with the topic of this volume.

The former Health Inequalities National Support Team, an excellent organisation that fell victim to the “Bonfire of the Quangos” in 2012,^10,11 spoke of three main ways to achieve change in population health: to maximise impact, interventions need to be made across the population, personal and community levels. At the population level, examples include national government taking forward plain packaging of cigarettes (great news on that front as this article goes to press¹²), councils and businesses enforcing “smokefree legislation”, or primary care professionals encouraging their patients to sign up to the local smokefree homes programme. Children are much more likely to smoke if their parents smoke. Shifting the norms of parental smoking is key to breaking the cycle of inequalities. Practitioners mainly act at the personal health level, applying effective individual health interventions, which when combined will impact upon population health. Smoking is the greatest cause of preventable death.¹³ Do you systematically refer your patients, particularly those at highest risk, to the local stop smoking service or run your own quality service? Community level action is engaging, developing and empowering communities effectively (see below). To impact upon population health inequalities, the three elements also need to be tackled systematically, rather than on an ad hoc basis, and at scale, rather than small, short term programmes.

Professor Sir Michael Marmot's 2010 review, “Fair Society Healthy Lives”,¹⁴ influenced national policy, and that influence outlived a change in government. Marmot advocates a “social determinants” approach, addressing the “causes of the causes”. This is essential to achieving lasting change and will be discussed in a future Public Health Prose. He states the importance of action across each stage of the life course: development takes place from birth to death. Marmot's proposal of proportionate universalism in programme delivery, while arguably tricky, is of practical importance to public health and general practice. Proportionate universalism gives a graded level of intervention, universal action but with a scale and intensity to match the level of need. It is important because the relationship between social circumstances and health is frequently a graded one: the higher a person's social position the better his or her health. For example, there is a graded response between level of deprivation and life expectancy by neighbourhood and of coronary heart disease mortality by social class.¹⁴ Targeting interventions at the very vulnerable or deprived can miss much of the burden of health inequalities that is distributed across the social gradient.

Let's now consider a proportionate approach by public health and primary care to increase the uptake and outcomes from NHS health checks. The affluent could receive written invites and limited offers of free lifestyle support. Most patients could have follow up calls/texts following a written invite and free lifestyle support according to severity. We could work with the deprived communities and vulnerable groups to put in place outreach programmes and accessible lifestyle support. This tactic could be taken forward with or irrespective of financial rewards to general practice for targeting.

Engaging, developing and empowering communities is central to reducing health inequalities and addressing differential uptake of, access to, and outcomes from services. Consider the question: are we dealing with “hard to reach groups” or “hard to reach services”? Communities can be involved in designing and delivering services. Social marketing – applying principles of marketing for social gain – uses insights and information (for example, from research with local people) to test and produce effective marketing materials or redesign services. One example of community delivery would be “community health champions”; volunteers from deprived areas trained to raise awareness of lifestyle issues and signpost appropriately within their own communities. Further discussion on the design and delivery of healthcare with authentic integration with local communities is discussed in this volume.¹⁵ Harnessing community resources is essential at a time of public funding crisis.

Reducing inequalities in health is a major challenge. Public health leaders need to work with Health and Wellbeing Boards, influence across the council, and work with our GP colleagues as commissioners and providers in order to rise to this challenge. The financial pressure on public services is hard and London councils have an imminent election. Health is everyone's business. Acheson argued that all policies may inadvertently increase inequalities unless appropriately targeted or implemented to avoid this.⁶ As health practitioners we need to proactively address inequalities to “above all do no harm”.

This prose is written in a personal capacity by Dr Fiona Wright. It does not express the views of any organisation to which I belong or by which I am employed. We would love to hear from you with comments, queries and thoughts. Address for correspondence: phprose@gmail.com