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There is little doubt that inequalities in health are difficult to tackle. In England the gap in life expectancy has continued to widen, despite bringing health inequalities increasingly into the mainstream of performance management in the NHS. However fast the most deprived areas or disadvantaged groups improve their health, everyone else's health improves faster. It sometimes seems that the most effective contribution to tackling inequalities in health that the professional classes could make is to be a little less healthy and die a little earlier.
In fact the government's strategy for health inequalities is now more akin to redistributing health than to redistributing income or wealth. Health is being redistributed pharmacologically by statins, antihypertensives, and nicotine replacement therapy. This is creating the paradoxical situation of a medical rather than a social model of public health, and a key role for pharmaceutical companies in a new definition of prevention based on drugs. The use of statins, for example, in the effort to narrow health inequalities has seen the term “primary prevention” get redefined not as upstream interventions in social and economic conditions but as treating people with risk factors but no observable disease.
Current government policy recognises the wider determinants of health and a commitment to policies on tax credit, housing, and family support targeted on those most in need to tackle these determinants. Recognition seems, however, to be growing that these are weak interventions for closing gaps in health outcomes because everyone else's incomes, housing, and family opportunities just improve faster.
Drugs seem to offer an opportunity to redistribute health, and quickly. The looming 2010 target for narrowing the life expectancy gap in England by 10% is focusing effort on pharmacological interventions among people in their 50s and 60s. This is the equivalent of teachers in schools focusing their efforts on students at risk of only achieving D grades in their GCSEs so that they are tipped into the A*-C category, which is the performance measure. As soon as someone is saved from a lethal heart attack before 75, he or she counts towards the target, even if he or she dies one day later.
Although extending these treatments as widely as needed is laudable, having so many people taking drugs can hardly be regarded as a public health achievement. Yet the NHS is proving remarkably good at these approaches. The reason for this is because the NHS is a sickness service, which is what it is good at and what it should focus on. Every attempt to push public health up the NHS agenda gets undermined by acute services trumping public health in budgetary, political, and media contests, or additional tranches of money getting diverted to priorities that are always more urgent than the slow and unglamorous interventions needed to improve the public's health.
If it seems a heresy to argue for the NHS to be the sickness service that is so often claimed in public health circles to be its weakness, then another shibboleth of public health is partnership working. This is held to be the solution to the silos of separate acute, primary, social care, and housing services that fail to “join up” and tackle “cross cutting” issues like health inequalities. Partnerships, however, are often marked by poor accountability, lack of leadership, and ambivalent commitment. This is because the partnership is expected to be something new rather than simply a meeting of organisations, each of which has its own clear purpose. The theory of shared priorities and targets is a good one; the practice is hard to find.
So where should the responsibility and resources for public health and tackling health inequalities lie? The obvious answer is with local councils, beyond the appetite of acute services, beyond the quick fix of statin prescriptions, and in the clarity of a single organisation with clear accountability and leadership as an agent of public health. Partnerships between local government and the NHS would then become a true meeting of the two sides of health, prevention, and treatment. In so far as treatment patterns may undermine the wider effort to narrow health inequalities, local councils' scrutiny committees could be charged with guarding against this by focusing their work on equity in health care.
Where could extra resources for a major local government public health function come from? From acute care, with the plans announced by the services reconfiguration white paper “Our health, our care, our say” to shift spending from acute services to primary care and prevention transferring this spending instead to local government. It would then be a decision for local councils as to whether the best use of this funding would be to transfer it back to the NHS or to use it, for example, to cut the local waiting list for social housing or to improve school meals. Whatever it did, it would have to be mindful of its health inequality targets, which would now lie clearly with the local council as its responsibility.
“The NHS is a sickness service, which is what it is good at and what it should focus on”