In one of our most popular and commented-on Time to Think Differently blogs last year, how they plan to reduce inequalities. Public Health England, on the other hand, has quietly launched a conversation about health inequalities. Why has it taken so long to get this done?
The Health and Social Care Act of 2012, for the first, placed an obligation on the Secretary, NHS England, and clinical commissioning group to take into account the reduction of health inequalities. Our work has shown that people with lower incomes or less education are not giving up unhealthy behaviors as quickly as other people, which is storing up health inequalities for the future. What happened to Make every contact count within the NHS? The Marmot Review highlighted the gap of 7 years in life expectancy and 17 years in disability-free living expectancy between the low-income groups and the high-income groups. Public Health England has not yet provided an analysis or strategy on how to tackle the issue. Richmond House last produced a plan on inequalities in 2008.
The news isn’t all bad. NHS England has demonstrated independence by allocating additional funding to more disadvantaged regions to better account for inequalities. (Although the budget freeze means that there won’t be much change in the near term, NHS England projections indicate they plan to make more progress by 2018/19), The NHS Equality and Diversity Council was refreshed and given more weight by David Nicholson as its chair.
There is no shared narrative between the Department of Health and NHS England, nor Public Health England, about what they do together to combat inequalities. Nor is there a clear understanding of who is responsible for what. Local authorities cannot reduce health inequalities solely by implementing their new public health duties, even though they play a crucial role. It is more important than ever that these leaders commit to tackling health inequalities by using the “big levers”: commissioning and incentives, as well as accountability.
What are the top priorities? The reforms have made NHS England the sole buyer of primary health care. It must use this power to reduce inequality. The National Audit Office lays out clearly, much of which is the Department of Health analysis, how the NHS can make rapid, significant reductions of inequalities of life expectancy by a greater emphasis on more systematic primary healthcare, such as in cholesterol and blood pressure control.
Public Health England must also demonstrate how it supports – or challenges – other departments in the government to do their part to tackle health inequalities. Its expertise in health impact assessments is a major tool for this. Public Health England must be willing to freely share and lend that expertise to other departments to ensure their impact assessments of the policy-making process fully consider the health inequalities impact of one decision or another. Treasury should benefit from this, as it needs to be involved more transparently in the debates about the effects of taxation policies on alcohol, sugar, and fat on public health. Public Health England, as the government’s chief advisor, needs to be more visible when it comes to feeding into these debates.
The Department of Health could, as it has been the quietest of all, explain how the Social Value Act is to be interpreted in the health care system. The Act requires all public service commissioning departments to consider social value, i.e., how the commissioned or procured services will improve the economic and social well-being of a region. The implications are potentially enormous for a healthcare system that spends more than PS100 billion a year. Why shouldn’t we be told about this by the Department of Health?
To return to Gabriel’s point, the battle against health inequalities could be lost. But the three system leaders who are key to tackling health inequalities do not have to be powerless. They can kick-start a national conversation and tell us what they will do to make a difference.