What can the NHS do to alleviate inequality?

“Some people might argue that health inequalities are a price worth paying for having a dynamic economy or focusing on economic growth as a prime mover in Scotland,” Dr Gerry McCartney, Head of the Public Health Observatory (PHO), told Holyrood back in 2013.

Under the UK coalition government, since 2010, large-scale reform of the UK’s welfare system has meant McCartney and his colleagues in NHS Scotland have had to take that argument head-on.

With health inequalities in Scotland wider than anywhere else in western and central Europe, the PHO, a collaboration between inequalities board NHS Health Scotland and health stats body ISD Scotland, examined the impact of years of recessions and welfare reform and found action was needed.

“Economic recession is likely to be bad for health – especially when accompanied by neoliberal policy responses,” concluded its paper in 2013, which suggested a move away from universalism and towards conditionality and privatisation in welfare was worsening health inequalities.

The NHS Outcome Focused Plan was published which set out principles for regional NHS boards to follow in developing action plans to mitigate the effects of welfare reform. These included raising awareness among NHS staff of the social determinants of ill-health and health inequalities, and how to recognise the changing social and economic conditions of patients so future services could be planned effectively.

The recent report by the Joseph Rowntree Foundation, Monitoring Poverty and Social Exclusion in Scotland, highlighted the work of NHS Highland, one of the health boards instrumental in drawing up the plan. The health board, which has been integrating health and social care services with Highland Council since 2012, was praised for tailoring its own action plan to take into consideration the unique challenges of the geographic spread of its users.

Julia Unwin, JRF Chief Executive, said: "All of us in government and local government as well as employers, housing providers and the NHS, need a shared focus to alleviate the impacts of poverty across all age groups."

“Many interventions may improve population health, although they won't necessarily help to reduce health inequalities”

NHS Highland, the report said, responded directly to welfare reform, “including working with employers to tackle stigma and also ensuring patients are provided with proof of an appointment to use if there is a clash with, say, a job interview. The Highland plan also aims to make the NHS more accessible to those in work, for example, by allowing self-referral or evening and weekend appointments. In doing this, it is thinking beyond the obvious impacts of welfare reform, fashioning answers to the ancillary problems of in-work poverty.”

The effects of welfare reform are more identifiable in the more densely populated areas. Glasgow’s population alone is set to lose £259m a year as a result of changes to the welfare benefits system, second only to Birmingham in the UK. Between 2003 and 2013, the number of jobseeker sanctions across Glasgow, Lanarkshire and East Dunbartonshire tripled.

Last year the ‘Deep End’ GPs in Glasgow, who work in the 76 most deprived surgeries in the city, held a meeting with other organisations, services, advice centres and groups in Glasgow to look specifically at ways to support patients who are claiming benefits.

One GP reported two patients in every surgery of 12 or 15 experience issues of poverty, sanctions and welfare reform, taking time away from management of medical conditions. The meeting concluded cooperation between services, a sharing of information and NHS badging of local systems could help welfare benefit applicants in the city.

Based on the work of the Deep End GPs, the Scottish Government is working with the Health and Social Care Alliance to pilot a link workers scheme, where seven surgeries in low-income communities are supported by a worker who can help people deal with financial, emotional or environmental problems caused by poverty, housing, debt and other outside factors by connecting them with other organisations or activities in their communities. The scheme will be evaluated in May 2018, with patient outcomes from the participating practices compared with eight practices outside the scheme. Ministers will then consider whether to roll it out further.

However, the efforts of the NHS and wider public health initiatives have done little to reduce health inequalities, according to the Scottish Parliament’s Health and Sport Committee, which produced its first report into health inequalities in January. “If real progress is to be made, significant efforts will have to be made across a raft of policy areas and by different agencies collaborating and working more effectively together,” the committee recommended.

Committee members also agreed “some interventions, for example, public health messages in relation to risky behaviours such as alcohol abuse, tobacco use, diet and exercise had been shown to have had little or no impact on health inequalities or, indeed, to have exacerbated them.”

The PHO itself has recognised the limitations of ‘downstream’ investment in tackling inequality. In its Informing investment paper, the body examined eleven interventions, based on available literature.

"Reducing health inequalities has been identified as a priority issue for the Scottish Government. Our results show that many interventions may improve population health, although they won't necessarily help to reduce health inequalities,” concluded McCartney.

The paper found the introduction of a ‘living wage’ generated the largest beneficial impact on health, and led to a modest reduction in health inequalities, while increases to benefits had modest beneficial impacts on health and health inequalities.

Income tax increases had a negative impact on population health but reduced inequalities, while council tax increases worsened both health and health inequalities, although the model looked only at the taxation increases rather than the potential for redistributive measures the increase might lead to.

The paper also found tobacco taxation had modestly positive impacts on health but little impact on health inequalities. Alcohol brief interventions had modestly positive impacts on health and health inequalities only when socially targeted, while smoking cessation and ‘Counterweight’ weight reduction programmes had only minimal impacts on health and health inequalities even when socially targeted.

"Whilst regulatory and tax options may not seem to be directly health related, they will save lives, and ultimately save the NHS precious money and resources. Interventions that redistribute income, such as increasing the standard rate of income tax or implementation of a living wage are among the most effective interventions for reducing inequalities and improving health,” said McCartney.

 “Future research in this area will consider an even broader range of interventions and outcomes," he promised.