Doran Technical Brilliance, Social Blindness? Health Inequalities and the NHS Tim Doran University of Manchester NPCRDC Health Inequalities and the NHS HERON Meeting, 7 April 2011
Dec 18, 2015
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
Health Inequalities and the NHS
NPCRDC
Typhus outbreak, Upper Silesia 1848
Health inequalitiesInequalities in the UK
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.”
Health Inequalities and the NHS
Inequalities in mortalityStandardised mortality ratios, 1921 - 1925
Pritchard J, “Mortality Mosaics” 2008
The twentieth centuryRecent history
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and the NHS
Inequalities in mortalityStandardised mortality ratios, 2001 - 2005
Pritchard J, “Mortality Mosaics” 2008
The twentieth centuryRecent history
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
sel
f-ra
ted
heal
th (p
er 1
,000
)
Health inequalitiesInequalities in the UK
Role of the NHS
The twentieth centuryRecent history
Health Inequalities and the NHS
Dahlgren G, Policies and Strategies to Promote Social Equity in Health
Determinants of healthRole of health care services
Health inequalitiesInequalities in the UK
Role of the NHS
Contribution of clinical medicineClinical intervention
Health Inequalities and the NHS
1) Royal College of GPs 2008; 2) British Medical Association 2009
Tackling health inequalitiesRole of health care services
Contribution of clinical medicineClinical intervention
“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]
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and the NHS
Benzeval et al Tackling Inequalities in Health 1995
Tackling health inequalitiesRole of health care services
Contribution of clinical medicineClinical intervention
• 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
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
Health inequalitiesInequalities in the UK
Role of the NHS
Contribution of clinical medicineClinical intervention
Health Inequalities and the NHS
Access to careDistribution of GPs
Benzeval M, Judge K. JPHM 1996; 18: 33-40
Patie
nts
per G
P
Cornwall
Oxford
shire
Bedfo
rdsh
ire
Cheshire
Leice
stersh
ireEa
ling
Hillingdon
Trafford
Kirkles
s
Sandwell
Rotherh
am0
500
1000
1500
2000
2500
Contribution of clinical medicineClinical intervention
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and the NHS
Access to careDistribution of GPs, 1996
Benzeval M, Judge K. JPHM 1996; 18: 33-40
Cornwall
Oxford
shire
Bedfo
rdsh
ire
Cheshire
Leice
stersh
ireEa
ling
Hillingdon
Trafford
Kirkles
s
Sandwell
Rotherh
am0
500
1000
1500
2000
2500
-30
-20
-10
0
10
20
30
40
Patie
nts
per G
P
Und
ersu
pply
(per
cent
age)
Contribution of clinical medicineClinical intervention
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
Contribution of clinical medicineClinical intervention
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
Contribution of clinical medicineClinical intervention
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
Health inequalitiesInequalities in the UK
Role of the NHS
Health Inequalities and 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
Health Inequalities and the NHS
Further information: [email protected]