Doran

Doran

Technical Brilliance, Social Blindness? Health Inequalities and the NHS

Tim DoranUniversity of Manchester

NPCRDC Health Inequalities and the NHS

HERON Meeting, 7 April 2011

DoranNPCRDC

Topics:

o A bit of history

o Health inequalities in the UK

o The role of the NHS in tackling health inequalities

Health Inequalities and the NHS

NPCRDC

Doctors and health inequalities

Health inequalitiesInequalities in the UK

Role of the NHS

Rudolph Virchow

• Omnis cellula e cellula• Virchow’s node• Virchow’s triad• ‘embolism’• ‘leukaemia’

• Cellular pathology• Anthropology• Autopsy

History


NPCRDC

Typhus outbreak, Upper Silesia 1848


Role of the NHS

History

“The absolute separation of school and church is more necessary in Upper Silesia than anywhere.”

“Artificial epidemics... are indicators of defects in political and social organization, and affect 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.”


Inequalities in mortalityStandardised mortality ratios, 1921 - 1925

Pritchard J, “Mortality Mosaics” 2008

The twentieth centuryRecent history


Role of the NHS


Inequalities in mortalityStandardised mortality ratios, 2001 - 2005

Pritchard J, “Mortality Mosaics” 2008



Role of the NHS


Doran et al, BMJ 2004;328:1043-5.

Geographical and social inequalities

1 2 3 4 5 6 70

20

40

60

80

100

120

North WestEastLondon

Socio-economic Class

Poor

self-

rate

d he

alth

(per

1,0

00)


Role of the NHS



Dahlgren G, Policies and Strategies to Promote Social Equity in Health

Determinants of healthRole of health care services


Role of the NHS

Contribution of clinical medicineClinical intervention


1) Royal College of GPs 2008; 2) British Medical Association 2009

Tackling health inequalitiesRole 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]


Role of the NHS


Benzeval et al Tackling Inequalities in Health 1995

Tackling health inequalitiesRole 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


Role of the NHS


SEPHO, Atlas of Coronary Heart Disease 2006

Meeting clinical needCoronary heart disease mortality and coronary revascularisation

Revascularisation rates, 2004/5CHD mortality rates, 2002-04


Role of the NHS



Access to careDistribution of GPs

Benzeval M, Judge K. JPHM 1996; 18: 33-40

Patie

nts p

er G

P

Cornwall

Oxfordsh

ire

Bedfordsh

ire

Cheshire

Leices

tersh

ireEa

ling

Hillingdon

Trafford

Kirkles

s

Sandwell

Rotherham0

500

1000

1500

2000

2500



Role of the NHS


Access to careDistribution of GPs, 1996

Benzeval M, Judge K. JPHM 1996; 18: 33-40

Cornwall

Oxfordsh

ire

Bedfordsh

ire

Cheshire

Leice

stersh

ireEa

ling

Hillingdon

Trafford

Kirkles

s

Sandwell

Rotherham0

500

1000

1500

2000

2500

-30

-20

-10

0

10

20

30

40

Patie

nts p

er G

P

Und

ersu

pply

(per

cent

age)



Role of the NHS


Primary CareAggressive 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



Role of the NHS


The Quality and Outcomes FrameworkAchievement by area deprivation quintile

Doran et al. Lancet 2008; 372: 728-736.

2004-05 2005-06 2006-07

Repo

rted

ac

hiev

emen

t



Role of the NHS


Recommendations for clinicians/medical educators

Contribution of clinical medicine Clinical intervention

RCP How Doctors can Close the Gap 2010

• 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


Role of the NHS


o Health inequalities • Are responsible for millions of years of lost life• Are not inevitable• Are socially determined• Require sustained political interventions

NPCRDC

Summary

o The role of the NHS• Is fundamental to tackling health inequalities• Identifying and meeting need• Provide access & continuity• Primary and secondary prevention


Further information: [email protected]

Doran

Documents

worse health

nhshealth inequalities

national health service

upper silesia

mortality mosaics

social organization

social blindness

social spectrum