Inequalities, it never rains but it pours (2017)

Foreword

Alice Wiseman, Gateshead Director of Public Health

I feel incredibly privileged to be presenting my second annual report as Director of Public Health for Gateshead. 

The annual report is a statutory function. It is required to be independent, in that it doesn't represent an organisational or political perspective, but instead sets out my professional view of the health and well-being of our communities in Gateshead.

This year's report, 'It never rains but it pours', focuses on inequality. The report describes how disadvantage can cluster and accumulate across the life-course. It explores how inequalities are experienced through the eyes of people in Gateshead and it attempts to give a platform for those people whose voices are often not heard loudly enough. Poor health outcomes are significantly more prevalent in communities that experience other hardships (for example; poverty). These patterns of illness highlight that health is considerably more complex than individual behaviour choices. 
I know many of you reading this will agree that it is completely unacceptable that: 

• Two babies, born on this day in Gateshead, could have as much as a 10 year difference in life expectancy due entirely to the circumstances into which they are born. 
• If you look beyond Gateshead those same babies could have as much as a 15 year difference in life expectancy when compared to the most affluent area in Britain. 
• Baby boy born in the most deprived communities in Gateshead can expect to live on average 73.2 years
• Baby boy born in the least deprived communities of the English borough with the highest life expectancy can expect to live on average 88.3 years
• Baby girl born in the most deprived communities in Gateshead can expect to live on average 76.9 years
• Baby girl born in the least deprived communities of the English borough with the highest life expectancy can expect to live on average 90.8 years

It is not fair that life chances are marked before these babies have even taken their first breath. The burden of ill-health falls hardest and fastest on those from low income backgrounds.

'Poverty is not an accident. Like slavery and apartheid, it is man-made and can be removed by the actions of human beings. '(Nelson Mandela)

Once born into this cycle of disadvantage, a person is more likely to experience, and accumulate, a range of poor outcomes over the course of their life, with those experiencing multiple difficulties often suffering unthinkable adversity, stigma and isolation. 

Despite much amazing work over recent decades, to improve health, inequalities in entirely preventable disease remain stubbornly persistent. In fact, in recent years inequalities in Gateshead appear to be growing.

Would it surprise you if I told you that health care only accounts for around 10% of a population's health?¹

There is increasing evidence that the current system is severely limited by its disproportionate focus on treating ill-health when it occurs rather than investing in the conditions and qualities that support health over a lifetime. 

'Why treat people and send them back to the conditions that made them sick?'²

This report considers the inequalities that are visible through a range of very different lenses. However, regardless of the lens you are looking through, the overwhelming message is the impact of economic disadvantage.

In this context health is broadly shaped by political, social, economic, environmental and cultural factors which in turn are affected by the distribution of power, money and resources including: family circumstances, personal and family wealth, social opportunities, housing, education, individual health status, environment and  employment, amongst others. Of course inequalities are not inevitable but it is important to recognise particular life experiences that increase someone's likelihood of disadvantage.

The moral case is strong but beyond this there is also a clear economic case for being concerned about inequalities in health. Being in good health is not just important to an individual but it is also important to the economy. The 'poor health poor wealth cycle' outlined in the report 'Health and Wealth - Closing the Gap in the North East' (North East Commission for Health and Social Care Integration) illustrates how ill-health drives poor productivity and vice versa.

'The ultimate source of any society's wealth is its people. Investing in their health is a wise choice in the best of times, and an urgent necessity in the worst of times'.³

My report aims to extend our understanding of the way health outcomes are shaped so we can consider whether there are more effective ways to tackle health inequalities. If we continue to address inequalities through existing approaches we will continue to see the same outcomes.

Adopting this perspective characterises a healthy person:

'not as someone free from disease but as someone with the opportunity for meaningful work, secure housing, stable relationships, high self-esteem and healthy habits.' (1)

'There is no greater inequality than the equal treatment of unequals.'(Felix Frankfurter)

It is really important that I acknowledge the work that has already started in some parts of Gateshead, recognising the need to address these growing injustices. It's not going to be easy. We are battling a tide of both uncertainty, particularly with finance, alongside the local impact on inequalities of national policies. The combination of these provides a perfect storm where, without concerted action, outcomes for the most disadvantaged in our community are set to get progressively worse. 

In order to equalise outcomes it is also important that we consider our approach to how existing resources (people, time, money) are distributed, so that those communities experiencing the greatest disadvantage receive the greatest level of resource.

To respond to these challenges, work to address inequalities, using a social determinants approach, needs to be jointly owned and collaboratively designed.

As I entered my second year in this role, and was choosing the focus of this years report, I spent time reflecting on what motivated me to choose a career in Public Health. The memory that stands out most was being driven by an enthusiasm and passion (in sometimes unsophisticated ways) to redress these injustices. 

And one of the reasons I love working in Gateshead is that I know people here really care and share this aspiration. 

Therefore, I am appealing to your sense of justice, your compassion, your purpose, the reason you chose your role (or it chose you). I'm asking you to think even more deeply and carefully about how we do more, systematically, to mitigate the negative impact of inequalities that are disproportionately experienced by some of our communities.

Strategic recommendations 

1. The Health and Wellbeing Strategy should be renewed, adopting a much longer term approach, with a strengthened vision to address inequalities. This needs to include measures to address the social determinants of health alongside prevention and early intervention at every level. 
2. Partners in Gateshead should shift the focus from managing the burden of ill health to promoting actions that create the right conditions for good health through the employment of a robust Health in all Policies approach.
3. The Council and its partners should target resources to those individuals and communities most in need. Robust evaluation of reach and impact should be undertaken regularly using a Health Equity Audit approach.

Read the full report. (PDF, 2 MB)

References

1. Health Foundation (2017) 'Healthy Lives for People in the UK', Health Foundation, London 
2. Marmot M. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury Publishing; 2015.
3. Stuckler D, Basu S. The Body Economic: Eight experiments in economic recovery, from Ireland to Greece. London:Penguin; 2014