Covid has accelerated the urgency in ensuring healthy equality. James Ward reflects on the ways in which health inequalities are being spotlighted and the plans to address them.
It has come to be widely accepted that health is not solely determined by an individual’s behaviours, their inherent risk factors, or the function of the health service. Health is also socially determined by people’s circumstances and particularly whether they live in poverty and/or experience discrimination. There is an inexorable, if uncomfortable, link between health, wealth, and wellbeing. Health inequalities are a product of the unequal distribution of social, economic, and environmental opportunities available to people and the communities in which they live. This is not new and has been the focus of many voluntary and community sector organisations working at the intersections of poverty, multiple disadvantage, health and wellbeing.
Identifying and tackling health inequality has received a significant amount attention amongst policymakers and institutions, largely as a result of the work of Professor Michael Marmot’s reviews in 2010 and 2020. There is also significant investment from funders including the National Lottery Community Fund, charities such as The Health Foundation and the Kings Fund. Tackling health inequality is a priority for Integrated Care Systems and in the NHS long-term plan.
Does this attention and investment mean we can be optimistic about eradicated health inequality in the near future?
I am cautious. In the ten years since Marmot’s original review we have seen further reductions in life expectancy for those living in the local authority areas impacted most by local authority spending cuts, people in marginalised communities are spending more of their life in ill health, and the UN highlighted the levels of poverty and the impact of austerity. These issues are only amplified by the pandemic. Covid-19 mortality rates are as unequally distributed across communities as other preventable deaths. Resilience to the pandemic differs by region and neighbourhood. There is clearly a lot to do, and even though there is the will to address inequity it is essential that efforts, resources, and learning is joined up and shared.
Integrated Care Systems (ICS), currently being introduced across England, are intended to bring together place based partnerships of health, local authority, care and voluntary sector providers to provide joined-up health and social care services. There is particular emphasis on tackling inequality with accountable roles within ICSs to address inequity in health and care provision. Whilst ICSs can play a pivotal role there is a risk of fragmentation and competing priorities across different initiatives. Whilst innovative approaches to public health approaches such as knife crime are welcome, these potentially compete in ICS with more traditional (medical) priorities. These priorities, outlined in the NHS long term plan, include smoking, problematic alcohol use and Type 2 diabetes.
Outside of ICS there are other initiatives areas funded by grants and or prioritised by charities which are at similar risk. Whilst priorities should not be mutually exclusive there are limitations. Resources are finite and diminished. Workforces in health and social care sectors have been battered by the pandemic. These systems are already at, if not exceeding, capacity for change. With these limitations, the complexity and increased demand how can these be joined up?
I would argue that the VCSE are particularly well placed to be the crucial link.
VCSE organisations not only work at intersections of inequity but also across different sectors, funders, and commissioning streams and are already central to responses to homelessness, domestic abuse and addiction
Who better then, to be able to draw together the learning from the various initiatives across health?
VCSEs also offer a community centred asset based approach required to truly tackle inequity as well as opportunities to engage and work with those who are most marginalised. The role of the VCSE set out in ICS is clear, however this must be
- both recognised and funded
- meaningful and the power held by health and local authorities shared to ensure VCSE involvement is collaborative and not tokenistic.
- Invested in to build capacity, capability and competence as this varies dramatically across places.
We know that many areas of deprivation receive lower rates of grant funding and have smaller VCSE sectors. Wakefield has which has just 1.1 charities per 1000 residents compared to a national average of 2.4. Our new work in Wakefield is currently mapping the sector to identify capacity gaps. It will support the sector to better meet the needs of residents. A whole place-based approach will be required to enable this change.
Finally, Marmot’s most recent review calls for investment in tackling inequity to be proportionate to the levels of deprivation experienced. The VCSE presents a unique opportunity to ensure that this is achieved through both its significant volunteer workforce as well as its insights in to the impacts of poverty from the perspective of those who experience it.
At the time of writing though how VCSE will be included in ICS is still unclear, possibly even to those who are planning its delivery by the deadline of April 2022. There is cause to be optimistic, but cautiously so.
James is a Principal Consultant with Rocket Science based in Newcastle. James works across the UK to support organisations delivering health and social care services. For more information on our work or how we can help you please get in touch with firstname.lastname@example.org
 Marmot, M., Allen, J., Boyce, T., Goldblatt, P., & Morrison, J. (2020) Health Equity in England: The Marmot Review ten years on. London: Institute of Health Equity