Technical Brilliance, Social Blindness?
Health Inequalities and the NHS
Tim Doran
University of Manchester
HERON Meeting, 7 April 2011
Doran
NPCRDC
Health Inequalities and the NHS
Topics:
o A bit of history
o Health inequalities in the UK
o The role of the NHS in tackling health inequalities
Doran
NPCRDC
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
History
Doctors and health inequalities
Rudolph Virchow
• Omnis cellula e cellula
• Virchow’s node
• Virchow’s triad
• ‘embolism’
• ‘leukaemia’
• Cellular pathology
• Anthropology
• Autopsy
NPCRDC
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
History
Typhus outbreak, Upper Silesia 1848
“Artificial
epidemics...
areof
“The absolute
separation
indicators
defectsisin
school andofchurch
more
political
and
necessary
in social
Upper Silesia
organization,
and affect
than anywhere.”
predominately those classes
that do not participate in the
advantages of the culture.”
“The answer to preventing
outbreaks in Upper Silesia is
quite simple: education,
freedom and welfare.”
NPCRDC
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
The twentieth century
Recent history
Inequalities in mortality
Standardised mortality ratios, 1921 - 1925
Pritchard J, “Mortality Mosaics” 2008
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
The twentieth century
Recent history
Inequalities in mortality
Standardised mortality ratios, 2001 - 2005
Pritchard J, “Mortality Mosaics” 2008
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
The twentieth century
Recent history
Geographical and social inequalities
120
Poor self-rated health (per 1,000)
100
80
60
North West
East
London
40
20
0
1
2
3
4
5
6
7
Socio-economic Class
Doran et al, BMJ 2004;328:1043-5.
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Determinants of health
Role of health care services
Dahlgren G, Policies and Strategies to Promote Social Equity in Health
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Tackling health inequalities
Role of health care services
“GPs have an important role in reducing health
inequalities. With unrivalled access to the heart of
communities, we can influence the health inequalities
agenda as practitioners, commissioners and
community leaders.” [1]
“It’s not my job to solve the problem. My job is to
solve the patient’s problem, not society’s problem.
[Health] outcomes… are actually nothing to do with
the health service but to do with wider society.” [2]
1) Royal College of GPs 2008; 2) British Medical Association 2009
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Tackling health inequalities
Role of health care services
• Ensure that resources are distributed between
areas in proportion to their relative needs
• Respond appropriately to the health care
needs of different social groups
• Promote a wider approach to developing
healthy public policies
Benzeval et al Tackling Inequalities in Health 1995
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Meeting clinical need
Coronary heart disease mortality and coronary revascularisation
CHD mortality rates, 2002-04
SEPHO, Atlas of Coronary Heart Disease 2006
Revascularisation rates, 2004/5
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Access to care
Distribution of GPs
2500
Patients per GP
2000
1500
1000
500
0
Benzeval M, Judge K. JPHM 1996; 18: 33-40
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Access to care
Distribution of GPs, 1996
2500
40
Patients per GP
2000
20
1500
10
0
1000
-10
500
-20
0
-30
Benzeval M, Judge K. JPHM 1996; 18: 33-40
Health Inequalities and the NHS
Undersupply (percentage)
30
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Primary Care
Aggressive case-finding and careful audit
o Glyncorrwg,
• population of ~1,800
• ranked bottom 5% for area
deprivation (64% SCV)
o Health centre, 1964 – 1987:
• screening for BP, smoking,
cholesterol, diabetes,
PEFR, BMI, alcoholism
• fully computerised in 1988
o Outcomes:
• Glyncorrwg SMR 0.95
• Gwynfi SMR 1.60
Tudor Hart J et al, British Medical Journal 1991; 302: 1509-13
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
The Quality and Outcomes Framework
Reported achievement
Achievement by area deprivation quintile
2004-05
2005-06
Doran et al. Lancet 2008; 372: 728-736.
2006-07
Health Inequalities and the NHS
Health inequalities
Inequalities in the UK
Role of the NHS
Contribution of clinical medicine
Clinical intervention
Recommendations for clinicians/medical educators
• Consider the impact of their practice on health inequalities
• Harness the power of student advocacy and action on the social
determinants of health
• Generate and share information on best practice concerning the
social determinants of health
• Highlight and advocate policies and programmes that benefit the
health of socially disadvantaged groups
• Work with public health specialist teams and local authorities to
develop programmes to promote and protect people’s health and
tackle health inequalities
RCP How Doctors can Close the Gap 2010
Health Inequalities and the NHS
Summary
o Health
•
•
•
•
o The
•
•
•
•
inequalities
Are responsible for millions of years of lost life
Are not inevitable
Are socially determined
Require sustained political interventions
role of the NHS
Is fundamental to tackling health inequalities
Identifying and meeting need
Provide access & continuity
Primary and secondary prevention
NPCRDC
Health Inequalities and the NHS
Further information: tim.doran@manchester.ac.uk