Bundle: Health inequalities

This bundle is part of the Place and Community pillar of our Post-Covid Councils project. Read more about our work here.

We published A step backwards: the Marmot Review ten years on on 3 March this year, and we also covered an update on health inequalities ten years after the original Marmot review, written by LGIU members, the Health Foundation. The report had a stark conclusion that in five priority areas health is “worse (since Marmot) for people lower down the socioeconomic hierarchy” in areas as wide as children’s life chances, realising everyone’s potential, ensuring everyone has a healthy standard of living, creating fair employment for all, and developing healthy and sustainable places.

Just three weeks later the UK was in lockdown. And what is already clear from a wide range of evidence is that Covid-19 has starkly exposed the existing inequality in health and wellbeing, but also that it will have in many cases made them worse. Our briefing considered the possible impact of Covid-19, again drawing on the work of the Health Foundation. Those already facing the greatest disadvantages in society have had a higher risk of exposure to Covid-19 and existing poor health puts them at risk of more severe outcomes if they contract the virus. The government’s and wider societal measures to control the spread of the virus and save lives now (including the lockdown, social distancing and cancellations to routine care) are exacting a heavier social and economic price on those already experiencing inequality.

Evidence

So what is the evidence? The deaths from the virus have shown, for example, a clear link between income and death rates with higher deaths in the most deprived areas. This is hardly surprising given that health outcomes are worse for those who are poor and that this relationship continues up the income scale: “Poor health is twice as prevalent for the bottom 40 per cent of people than it is among the top 10 per cent and even being in the top 10 per cent is associated with better health than being merely in the top 30 per cent.” Health Foundation). Covid affects the elderly most, but also those with related health conditions.

We also know certain occupations are more vulnerable to Covid-19. ONS data shows that men working in what are classified as ‘elementary’ occupations had the highest rate of death involving Covid-19, such as packing goods and security. The links between income and health are complex as different factors interact with each other, but the relationship is clear enough.

The impact of the Covid-19 lockdown on specific groups is also reasonably clear, such as people on low wages being seven times as likely as high earners to work in a sector that has closed down leading to economic insecurity, and that low income jobs were more likely to mean having to go to work rather than working at home and being more exposed to the virus. Poorer people were less likely to have access to gardens or were living in more crowded situations: green space helps to promote both physical and mental wellbeing. Children in low income families had fewer opportunities to have home schooling during lockdown. There are many more examples of the differential effects of the response to Covid-19.

People with existing health conditions are more likely to die from Covid-19 and existing health inequalities mean that it is the already disadvantaged who are more likely to be in this group. The WHO explains that “people with disability experience poorer health outcomes, have less access to education and work opportunities, and are more likely to live in poverty than those without a disability”. For example, across the EU, less than one person out of two with basic activity difficulties is employed, according to Eurostat.

Evidence from the West Midlands shows that underlying health conditions have increased the risk of serious consequences from infection with 8.2 per cent of the region’s population (compared to 6.8 per cent nationally), for example, having diabetes – a condition reported on more than 20 per cent of death certificates for Covid-19. ONS figures from mid-May analysed by the Health Service Journal (HSJ) indicate that Northern towns in the North West, North East and West Yorkshire are becoming the worst hit from Covid-19 in terms of persistently higher rates, cumulative infection rates and excess deaths. Local lockdowns, so far, have been more prevalent in parts of the North West and the Midlands.

The impact on Black, Asian and minority ethnic communities groups has had the most high profile exposure – in the UK, but also globally. The pandemic has highlighted the structural disadvantage and systemic discrimination faced by BAME groups. We are exploring this further in the Place and Community pillar of our Post-Covid Councils work and have published briefings, bundles and articles, such as Covid-19: It’s not equal in the end and Covid-19: Government needs to get specific about protecting BAME people.

Role of local government

Tackling health inequalities at the local level has always been difficult but the pandemic has made it both harder and more critical.

Our briefing on Covid challenges and health inequalities outlined some of the initiatives some councils were leading on, such as the West Yorkshire and Harrogate Health and Care Partnership that works to principles of shared ambition, shared leadership, simplified decision making and subsidiarity. Much of its work is at place level. WY&H also works with West Yorkshire Combined Authority on shared priorities, maximising the mutual benefits of inclusive growth and, for example, leveraging the economic and health benefits of the med-tech industry in Yorkshire. Because of health inequalities connected to coronavirus, WY&H is working with the local resilience forum, the combined authority and other partners on a collective approach to supporting people judged to be vulnerable and excluded and those hardest hit, including BAME communities, people with mental health problems or learning disabilities, carers, and those in poverty.

The briefing outlined other ways that councils can take action locally, such as capitalising on the public’s interest in better health and healthier lifestyles, and on the use of digital media for exercise and health advice which exploded during the lockdown and presents opportunities to engage with people on improving their health, in a way which, once the basics are in place, can be both effective in terms of outcomes and costs.

Councils can also build on the rise of volunteering and community action that happened in lockdown, working with partners in the third sector – harnessing the strengths and ideas of local communities and target resources at supporting local people and specific groups to help each other to improve health. It is crucial that councils actually involve those groups and individuals that have fared worst in the pandemic – in establishing the evidence about what has happened to them and in developing strategies and policies for recovery.

We have published a series of briefings on specific issues, such as tackling obesity, promoting local food, and active transport – all of which make a contribution to improving life chances and the wellbeing of communities and to reducing health inequalities.

The key role of councils is, though, in influencing the wider determinants of health – housing, planning, sustainable transport, the state of local economies. There is a myriad of challenges and barriers, many of which Covid-19 has made worse. A decade of cuts, for example, has meant for many crucial public services there has been a shift from prevention to late intervention. Local government can do little on its own – there needs to be collaboration and a shared vision at the local level and greater integration between public health and other services and functions, such as economic development and health.

At the national level, the UK government and the governments of the devolved administrations have to have a specific focus on health inequalities. We haven’t seen this emerge yet – indeed, the decision to abolish PHE by the UK government without any clear way forward for those critical functions that will not be part of the new body, is a step backward.

It is clear that whatever direct and indirect impact Covid-19 has had so far on places, communities, groups and individuals is not the end of the story (plus the evidence can be disputed at times and the picture changes all the time). The steep rise in unemployment that we know is coming, the uncertainty over the course of the virus itself, and any future cuts to public services are bound to increase the pressures on local authorities and to further exacerbate disadvantage groups. This is how the Health Foundation puts it:

“As we move from crisis management to recovery, government, businesses and wider society all have a role to play in giving everyone the opportunity to live a healthy life. Restoring the nation to good health will require a new social compact, backed by a national cross-departmental health inequalities strategy. Action needed will include protecting incomes, improving the quality of jobs and homes, and supporting critical voluntary and community services”.

In our March 3 blog, I wrote that we know that councils are doing excellent work to tackle the social determinants of health and, as important, are empowering communities to take action themselves but that there needs to be a reinvigorated debate about policy responses to the growing health inequalities gap – it was a high profile issue after the 2010 Marmot report but it seemed to lose impetus since. How much more urgent is that debate now?