Making a difference to health inequalities
The imaging and oncology workforce is diverse but we can all contribute to improving health equity
We often associate health with medical systems – attending appointments with the general practitioner (GP) or at hospital to identify or treat ill health. But health really starts in the community and, when we begin to consider how health varies across communities, the inequalities we observe are stark. Where you live will determine more about your chances in life than you might ever have considered.
A book from 2013 outlined that between the first four stations on London Underground’s Central Line, life expectancy falls by one day per second travelled for those living along the tube line1.
A more recent article, “A wall divides our city”, explores a three-mile area of Sheffield. In education, health, housing and employment, the variation in outcomes across such a small geographic area is alarming2. Health inequalities have existed for many years and individuals, organisations and government bodies have been trying to close the gaps for a long time.
The policy context
All four nations of the United Kingdom have acknowledged health inequality through current public health strategies and in wider health policies. In 2022, the government published the Levelling Up white paper3. Recognising levelling up as a “moral, social and economic programme for the whole of government”, it set out how opportunity will be spread more equally across the UK.
Northern Ireland
Securing the Health and Wellbeing of our Population 2022-2027 informed the public debate ahead of the May 2022 Northern Ireland Assembly elections4. The paper specifically outlined the need to focus on prevention and address inequalities through integrated care and a greater focus on prevention and early intervention. The longer-term Making Life Better, a Strategic Framework for Public Health5 further strengthened the Northern Ireland focus on health inequalities. This strategy set out an overall vision to ensure that all people are enabled and supported to achieve their full health and wellbeing potential, to achieve better health and wellbeing for everyone and to reduce inequalities in health.
Scotland
The Public Health Scotland strategic plan6 indicates that reducing health inequalities is a priority area. In addition to work outlined to target the factors that influence health, such as poverty, income inequality and place, the plan also outlines the role of public bodies to address some of the drivers of inequalities, achieve net zero targets and contribute to community wealth building locally. The Minister for Public Health also established a Ministerial Task Force on Health Inequalities7 in 2007, designed to prioritise the actions required to reduce the widening health inequalities in Scotland. The Task Force monitors a range of health indicators over time, producing an annual report, most recently in March 20228. The annual updates enable the monitoring and identification of trends, with the most recent report highlighting that, with the exception of one area, significant inequalities continue to exist across the indicators included in the report. It does, however, demonstrate that the inequality gap is narrowing.
Wales
The Public Health Wales Strategic Plan 2022-20259 outlines the need to understand what is required to mitigate the risks of growing health inequalities. The approach to tackling health inequalities is woven throughout this action-focused strategy, but there is a specific commitment to collectively restore and measurably improve population health as measured by healthy life expectancy and health equity.
England
More specifically in England, the Core20PLUS510 approach aims to accelerate improvement in inequalities through a focus on the most deprived 20% of the population, the defined PLUS population groups and five clinical areas of focus. The same approach has also been adopted for children and young people. Protecting and improving the nation’s health sets out the longer-term public health strategy for England11. Within the priority areas identified in the strategy, there is a focus on reducing unjust and avoidable inequalities in health outcomes that are observed across communities.
Focusing on England but adopted more widely, the seminal paper, Fair Society, Healthy Lives, published by Marmot et al.12 (2010), explained that to reduce health inequalities, action was required across six policy areas:
1. Give every child the best start in life.
2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.
3. Create fair employment and good work for all.
4. Ensure a healthy standard of living for all.
5. Create and develop healthy and sustainable places and communities.
6. Strengthen the role and impact of ill-health prevention.
In 2020, Marmot et al. published The Marmot Review 10 Years On13 and the trends demonstrate that health is worsening. Marmot explains that this statement, included in the original 2010 report, holds true in the present day:
“Health inequalities are not inevitable and can be significantly reduced. Avoidable health inequalities are unfair and putting them right is a matter of social justice. There will be those who say that our recommendations cannot be afforded, particularly in the current economic climate. We say that it is inaction that cannot be afforded, for the human and economic costs are too high.” Marmot et al. (2010).
The scale of the challenge
Even for those unfamiliar with the work of Marmot et al., the Covid-19 pandemic put health inequalities in the spotlight. Poor health and existing inequalities resulted in parts of the country experiencing greater vulnerability to the virus. It was identified that individuals in the poorest 10% of areas in England were almost four times more likely to die from Covid-19 than those in the wealthiest14. We know inequalities exist within communities, defined by geographic or other means. We all have a responsibility to contribute to closing health inequalities.
Irrespective of the pandemic, health inequalities have been a growing area of concern for many years. Inequalities result in premature mortality and a reduced number of years of healthy, good-quality life. There are many ways to assess the state of health inequalities and “life expectancy” is one common measure. Alarmingly, over the past decade, the gap in life expectancy between most and least deprived locations has grown. Before this, life expectancy had improved since the 19th century but, in 2020, there was an alarming decrease, likely attributed to the pandemic. It should be noted, however, that life expectancy has been stalling and inequalities widening since 2011.
While the pandemic is likely to be a key influencing factor in the sharp decrease in life expectancy, it is not the only reason. Recent statistics15 prepared by the Office for National Statistics outline that in the period 2018 to 2020, male life expectancy at birth in the most deprived areas of England was 73.5 years, compared with 83.2 years in the least deprived areas. For females, the equivalent estimates were 78.3 years and 86.3 years, respectively. In 2018 to 2020, male healthy life expectancy (HLE) at birth in the most deprived areas was 52.3 years, compared with 70.5 years in the least deprived areas. Female HLE at birth in the most deprived areas was 51.9 years, almost 20 years shorter than for those living in the least deprived areas (70.7 years)15.
Access to health and care services
Although a useful metric, inequalities are not just observed through mortality or life expectancy. They are also observed through a person’s access to health and care services, receipt of care, including experience of care, and risk factors associated with health outcomes. It is understood that inequalities in health begin early in life, where there are disparities between poorer and more affluent communities. This is reflected in statistics where levels of infant mortality, low birthweight, childhood obesity, tooth decay and adverse childhood experiences are increased.
Throughout the life course, similar inequalities are observed across a wide range of measures. These include health conditions and risk factors, where people living in deprived communities are more likely to smoke, have a poor diet, be physically inactive and die early from cancer or heart disease11. Individuals are commonly affected by several factors that lead to inequalities. Often referred to as intersectionality, there is a growing body of evidence surrounding this.
Although the root causes of health inequalities are mostly preventable, they are complex and challenging to address. They exist due to numerous factors, many of which relate to the community in which a person lives, and specific characteristics such as age, disability, geographic location and socioeconomic conditions. The complexity and intersectionality of the factors leading to inequalities is important for us to understand, even in roles where we might meet individuals at the point of need of imaging or oncology services.
The social and economic factors that impact on health are referred to as the social determinants of health. They are best explained through this ever relevant diagram (Figure 1), produced by Dahlgren and Whitehead16. Through this diagram and accompanying narrative, they describe a social ecological theory that considers the many influences on an individual’s health.
Figure 1. Social determinants of health
As outlined in the King’s Fund publication My Role in Tackling Health Inequalities – a Framework for Allied Health Professionals17, those working in clinical, public/patient facing roles have likely experienced this at first hand. You might have observed the impact of poverty, low health literacy, homelessness, unemployment or a lack of social support on a person’s ability to understand and engage with their care.
You might also have observed how these factors make an impact on a person’s ability to take preventative action to avoid ill health. For those in roles associated with managing or designing services, you might have noticed an absence of fair representation across communities, meaning individuals who are most at risk of the impact of inequalities – and the most in need of having a voice in how health services are designed – are seldom heard.
Although a useful metric, inequalities are not just observed through mortality or life expectancy. They are also observed through a person’s access to health and care services, receipt of care, including experience of care, and risk factors associated with health outcomes. It is understood that inequalities in health begin early in life, where there are disparities between poorer and more affluent communities. This is reflected in statistics where levels of infant mortality, low birthweight, childhood obesity, tooth decay and adverse childhood experiences are increased.
Throughout the life course, similar inequalities are observed across a wide range of measures. These include health conditions and risk factors, where people living in deprived communities are more likely to smoke, have a poor diet, be physically inactive and die early from cancer or heart disease11. Individuals are commonly affected by several factors that lead to inequalities. Often referred to as intersectionality, there is a growing body of evidence surrounding this.
Although the root causes of health inequalities are mostly preventable, they are complex and challenging to address. They exist due to numerous factors, many of which relate to the community in which a person lives, and specific characteristics such as age, disability, geographic location and socioeconomic conditions. The complexity and intersectionality of the factors leading to inequalities is important for us to understand, even in roles where we might meet individuals at the point of need of imaging or oncology services.
The social and economic factors that impact on health are referred to as the social determinants of health. They are best explained through this ever relevant diagram (Figure 1), produced by Dahlgren and Whitehead16. Through this diagram and accompanying narrative, they describe a social ecological theory that considers the many influences on an individual’s health.
Figure 1. Social determinants of health
As outlined in the King’s Fund publication My Role in Tackling Health Inequalities – a Framework for Allied Health Professionals17, those working in clinical, public/patient facing roles have likely experienced this at first hand. You might have observed the impact of poverty, low health literacy, homelessness, unemployment or a lack of social support on a person’s ability to understand and engage with their care.
You might also have observed how these factors make an impact on a person’s ability to take preventative action to avoid ill health. For those in roles associated with managing or designing services, you might have noticed an absence of fair representation across communities, meaning individuals who are most at risk of the impact of inequalities – and the most in need of having a voice in how health services are designed – are seldom heard.
How can you make a difference?
The imaging and oncology workforce is diverse but, regardless of role, we can all contribute to reducing health inequalities. The Health Inequalities Framework17 provides an excellent foundation to outline the opportunities across the imaging and oncology workforce. The framework helps us to consider how we can contribute to reducing health inequalities, irrespective of role.
First, take the time to reflect on your own views and experiences of health inequalities, including your biases. There are a number of resources that can support you with developing your knowledge and understanding of health inequalities, including those explained above. Sharing your reflections within your team or department can also help to create open dialogue about health inequalities and encourage your peers to undertake similar reflection.
Second, consider how you can ensure that those using your services (if you are patient facing or otherwise) are cared for equally. This could include making sure you and colleagues working in your team or service are aware of local or national signposting services that might support an individual beyond their need for your service. You could consider any barriers to accessing information about the services you provide, such as language and health literacy.
A review of service design is also important – this could be of value to those working in screening services but it is also applicable more widely. You could review data to learn more about your local populations and their health. There are a number of existing tools to help you do this. Understanding more about your populations can help you design, modify or redesign services that better meet their needs. By taking time to speak to staff, local people and partners at all levels to find out about the real issues they are seeing, what local needs are, the gaps and opportunities, and where the energy and passion is for tackling health inequalities will help you ensure that your service is meeting the needs of all.
For those in leadership or management roles, it might be helpful to identify if your organisation has a health inequalities lead and, if so, you could discuss priority areas or ask them to present to your team.
Without greater awareness and action, the health inequality gap will not close: “Inequality in the UK is like water must be to fish – so omnipresent, such a fixed part of our daily lives, that most of us don’t even notice it’s there”2.
Laura Charlesworth is Head of Health Research at New Local, an independent think tank and network of councils with a mission to transform public services and unlock community power.
References
1. Dorling D. The 32 Stops: The Central Line. Penguin. 2013.
2. Dowdeswell A. A wall divides our city. The Tribune. 14 January 2022.
3. HM Government, Levelling Up the United Kingdom. 2022.
4. Northern Ireland Confederation for Health and Social Care. Securing the Health and Wellbeing of our Population 2022-2027. 2022.
5. Department of Health. Making Life Better – Strategic Framework for Public Health. 2013.
6. Public Health Scotland. A Scotland Where Everybody Thrives: Public Health Scotland’s Three-Year Strategy to Improve and Protect the Health and Wellbeing of People in Scotland. 2020.
7. Scottish Government. Background and methodology. Monitoring Health Inequalities. 2007.
8. Scottish Government. Long-Term Monitoring of Health Inequalities. March 2022 report. 2022.
9. Public Health Wales. Our Strategic Plan 2022-2025. 2022.
10. NHS England. Core20PLUS5 (adults) – an approach to reducing healthcare inequalities. 2022.
11. Public Health England. Public Health England Strategy 2020-2025. 2020.
12. Marmot M et al. Institute of Health Equity, Fair Society, Healthy Lives. 2010.
13. Marmot, M et al. Institute of Health Equity, The Marmot Review 10 Years On. 2020.
14. The Health Foundation. Unequal Pandemic, Fairer Recovery. 2021.
15. Office for National Statistics. Census 2021 – data and analysis. 2021.
16. Whitehead M and Dahlgren G. What can be done about inequalities in health? The Lancet, Public Health. 1991. 338, 8774, 1059-1063.
17. The King’s Fund. My Role in Tackling Health Inequalities – a Framework for Allied Health Professionals. 2021.
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