1.0  EXECUTIVE SUMMARY

—  The RCN welcomes the Government's announcement that extra funding would be targeted at reducing health inequalities. However, further progress is still to be made, not just in health, but in areas such as fiscal policy, employment, housing and education.

—  Health services should be targeted towards those living in the most economically deprived areas, who are often the most difficult to reach and the most at risk of ill health.

—  There is a shortfall of midwives, school nurses and health visitors across the UK and greater investment is needed in recruitment and retention of the nursing workforce.

—  Those with learning disabilities or mental health problems remain a low priority in health and social care and dramatic improvements are needed to assist this sector of society.

—  Those in employment who are financially self-sufficient are generally thought to experience better health and thus we are supportive of programmes such as the Improving Lives and Choosing Health which aim to support people in and returning to work.

—  The RCN wishes to see more high quality developed general practice and community nursing services in areas which are currently underserved. We would also like more consideration to be given to how the Quality and Outcomes Framework (QOF) can be amended to increase the general practice incentives for providing services which aim to reduce health inequalities.

—  We would like to see an English health promotional organisation re-instated that would be empowered to lead and co-ordinate targeted and influential campaigns.

2.0  INTRODUCTION

  2.1  With a membership of over 390,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

  2.2  Many of our members are community nurses, health visitors and midwives that work in the community and are vital to reaching those at most need. Nurses can play a vital role in promoting healthier lifestyles to patients and those nurses working in the community, in schools and with the most vulnerable groups of patients are well placed to promote the public health agenda and tackle health inequalities.

  2.3  The RCN welcomes the opportunity to make a written submission to the inquiry of the Health Select Committee.

3.0  The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government.

  3.1  The link between health inequalities and social inequalities is well known and accepted, with a marked difference in life expectancy and morbidity between socio-economic groups 1 and 5.[71] We recognise that whilst the health service alone cannot completely ameliorate health inequalities, high quality and accessible primary health care services can make a significant contribution to health improvement by tailoring services to those in greatest need. The Dawson Report (1920) called for improved primary health care and the provision of health care centres in places where poor people lived in the belief that such services would greatly enhance the lives of these people. At the beginning of the NHS Nye Bevan highlighted how inadequately general practice was distributed and that it was the middle and upper classes that had far better access to a greater number of GPs than the more needy, less healthy people living in economically deprived areas.

  3.2  It is a shocking fact that a similar situation exists today, which is why the RCN welcomed the recent announcement by the Secretary of State for Health that extra funding would be targeted towards areas of people with the poorest health. This aims to ensure that more general practice will be developed, thus helping to ease existing gaps in GP services.

  3.3  However, this development must not diminish the many improvements which still need to be achieved in fiscal policy, secure and gainful employment, housing and education. All of these can bring benefits to lifestyle, life chances and health.

  3.4  Targeting the health of disadvantaged groups is key to reducing health inequalities. Doing so can both assist in equalising access to services and equalising outcomes from health care interventions. The RCN believes in redesigning health services so that they focus on those most in need in order to compensate for poorer health status. Well developed general practice and community health workers, such as health visitors, school nurses and community midwives, can make a major contribution by reaching those people in greatest need.

  3.5  The way in which local services are provided to the poorest people within the community needs consideration. Regional, economic and social disparities ensure that certain sections of society fail to participate in the decision making process to the detriment of their health needs.

  3.6  If a reduction in health inequality is to be achieved, the role of children and families will be crucial. There is evidence to suggest that early years experiences can be a protective factor against social disadvantage in later life. For example, research has demonstrated significant improvement to the birth weight of babies born to low income mothers who received tailored support from midwives during pregnancy.[72] Pregnancy and the early years are a crucial period in which attention must be paid to supporting parents to nurture the physical and emotional wellbeing of their children. Educating and investing in families is the most effective way of empowering people to take control of their own health, and both midwives and health visitors are the professionals best placed to provide such support. However there is a shortfall of midwives and health visitors across the UK and those who are practicing face numerous workload and time pressures.

  3.7  People with learning disabilities remain a low priority in health and social care. Following the "Treat me right" campaign by Mencap in 2004 little has improved for this group of people in our society. People with learning disabilities continue to die younger than others and we believe this is avoidable.[73] The Department of Health's Learning Disability Taskforce Annual Report 2006-07 reported that poor progress had been made in respect of health, housing and employment for such people.

  3.8  It is recognised that people with severe and enduring mental illness have poorer physical health outcomes than those who do not. While the causes of this are multi-factorial; such as the use of anti psychotic medication, lifestyle, social exclusion and poor interactions with primary health care professionals, the interventions needed to improve this situation are more simple. Good access to primary health care and health screening provided in a manner which is sensitive to client need is effective and should be more widely spread. Nursing interventions such as the RCN accredited "Well Being Programme" has demonstrated how well-prepared and supported nurses can help people adapt their lifestyles and enjoy better health.  

  3.9  A study of refugee and asylum seeking women in 2002 reported that of those interviewed fifty-six per cent suffered from depression, barely half had access to interpreters when visiting their doctor and only seventeen per cent described their English as good or fluent.[74] The RCN is concerned that difficulty with communication and inadequate translation services could lead to neglect or inappropriate treatment.

  3.10  It is generally accepted that those people in work who experience relatively secure and well paid employment and are financially self sufficient enjoy a better standard of health and wellbeing than those who are unemployed. The Health, Work and Wellbeing strategy builds on the work of Improving Lives and Choosing Health which aim to support people in and returning to work. The workplace can be therapeutic and health enhancing, therefore improving the nation's health and reducing the number of socially excluded.

  3.11  The RCN supports the strategy recommending the provision of professional advice and guidance on work related health issues to those of working age via a range of stakeholders including the occupational health, primary care and mental health sectors. We acknowledge that this is a long-term strategy and a change of culture is required within health care and society. Work and unemployment are critical to reducing health inequalities and deserve greater attention.

  3.12  It appears that age is also a determinant of health inequality. 1.8 million pensioners live in poverty, two-thirds of whom are women. Seventeen per cent of all pensioners and thirty-two per cent of older people from black and ethnic minorities live in poverty.[75] The Governments annual report "Opportunity for All" states "it is essential that we continue to tackle poverty among older people". However, it is clear some groups of older people are more at risk from poverty, and thus ill health, than others.

  3.13  The RCN welcomes the extra allocation of funds to spearhead PCTs. However, we wish to highlight our concerns over the PCTs which fail to attract extra funds despite their poor public health records. It would be preferable to have a gradient approach, thus ensuring that PCTs with poor public health records currently falling outside the margins necessary to receive funding would still obtain some financial support.

4.0  The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities.

  4.1  The RCN wishes to see more high quality developed general practice and community nursing services in areas which are currently underserved. We would also like more consideration to be given to how the Quality and Outcomes Framework (QOF) can be amended to increase the general practice incentives for providing services which aim to reduce health inequalities. The QOF is an excellent way of managing long-term conditions but in its current form does little to encourage people to attend their local practice before they begin to feel the effects of chronic disease.

  4.2  General practice, with its registered list, is an ideal setting for promoting good health to the least healthy thereby improving quality of life and increasing life expectancy. However, the registered list can not be solely relied upon as it does not include the homeless or asylum seekers. We would urge PCTs and practice-based commissioners to expand the community nurse workforce and concentrate community health services in areas known to have large numbers of people who smoke, are overweight or inactive. The RCN also looks forward to the publication in late 2008 of the King's Fund report "Kicking Bad Habits: How can the NHS help us become healthier?" which will look at the interventions that are effective in encouraging healthy behaviour and the way in which the NHS can help people become healthier.

  4.3  There is huge variation around the country regarding the understanding that GPs have of learning disabilities. There are some very good examples of practice but these are not widespread. In July 2007 the Secretary of State for Health announced that an independent inquiry was to be established to look at access to healthcare for people with learning disabilities. The inquiry will look to identify the action needed to ensure adults and children with learning disabilities receive appropriate medical treatment in primary and secondary care and we look forward to receiving the results of this inquiry.

5.0  The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective.

  5.1  The RCN welcomed the Government's ban on tobacco advertising and smoking in public places and we believe the resources devoted to smoking cessation will continue to have a positive impact. Too many young people start smoking and continue to smoke into adulthood, finding it difficult to break this addictive habit. Nicotine Replacement Therapy helps the addicted smoker quit, but a significant number do well with added personal and skilled support. Once again, it is generally found to be less advantaged people who continue to smoke and who require more support if their lifestyles are to improve.

  5.2  Furthermore, obesity rates are higher amongst the least wealthy and a range of services are required to tackle this issue. The RCN supports the Food Standards Agency's position on the clear and simple labelling of food.

  5.3  The RCN also supports initiatives to ensure women are well-informed about the health benefits associated with breastfeeding. Breastfeeding has been shown to reduce health inequalities, improve the health of the mother and child and be cost effective. The RCN is a member of the Breastfeeding Coalition and supports their manifesto pledge calling for the marketing of formula milk to be controlled to the marketing standards set by the World Health Organisation International Code and subsequent resolutions.[76] Rates of breastfeeding remain lowest amongst the most economically deprived and action needs to be taken to promote breastfeeding to this sector of society and to limit the advertising of breast milk substitutes.

  5.4  Nonetheless, the effectiveness of national large scale health promotion campaigns is variable. Health promotion messages tend to be taken up first by the more socially advantaged, but little is ever done to monitor the impact that health promotion strategies have on the health gap between rich and poor. Evidence shows that health promotion messages often have the dual impact of improving health but also widening health inequality. Monitoring the impact of health interventions is an important role for health services, not least because there may be additional and compensatory measures that could be introduced.

  5.5  In Scotland, Northern Ireland and Wales health promotional activity is centrally co-ordinated through a dedicated organisation. However, in England health improvement campaigns are managed by commissioned organisations. As a result there is little evidence of how priorities are agreed, information distributed and professionals enabled to promote these campaigns. We would like to see an English health promotional organisation re-instated that would be empowered to lead and co-ordinate targeted campaigns.

6.0  Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective.

  6.1  While the RCN supported the principle of Health Action Zones, nurses were concerned that their creation led to an increase in geographical health inequalities, since not all socially deprived areas were in a Health Action Zone and thus lacked the extra resources associated with this status. The RCN welcomes any direction from Government that encourages joint working between relevant departments and agencies.

  6.2  Although the current evidence base for the Sure Start initiative is not conclusive, there is anecdotal evidence to suggest that these centres have been successful in assisting the most vulnerable children and parents in society. Health inequalities arise out of a complex range of factors and are generally the result of long-term effects that require a long-term programme. We hope that the Government's continued investment in Sure Start Children's Centres will assist in reducing these inequalities in access to health services whilst also widening social care support by encouraging and enabling nurse-led innovations.[77]

  6.3  The RCN particularly welcomes the initiative, Nurse Family Partnerships, aimed at helping children living within vulnerable families and we look forward to supporting the specially trained health visitors and other nurses involved in this important work.

7.0  The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care.

  7.1  The success of NHS organisations at coordinating activities with other organisations varies widely and it is considered that even where there is effective integration between organisations, relationships can suffer when finances are severely stretched. Despite organisational cultural challenges the RCN wishes to see cross-organisational incentives and levers in place. These incentives should be aimed at reducing health inequalities and improving the life chances of children.

  7.2  Where more established Children's Trusts are in place we are beginning to see a joined up approach to addressing health issues by pooling finances and targeting services.

  7.3  In learning disability services, shifting responsibility for the provision of care has led to increased marginalisation, both of service users and the practitioners who care for them. Where services have been provided through mental health trusts or through independent sector organisations, standards of commissioning are inadequate due to the lack of input from service users and learning disability practitioners into the commissioning process.

8.0  The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meet its Public Service Agreement targets for reducing inequalities.

  8.1  In order for health inequality targets to be met the gap in life expectancy between different social groups needs to be narrowed. This means moving towards health services for secondary prevention and effective treatment of coronary heart disease and cancer. Whilst we welcome the recent publication of the Cancer Reform Strategy[78] there is still more to be done and public health statistics confirm that there remains a variation in health across the UK with some areas requiring targeted action.

  8.2  Whilst the 2007 Department of Health report "Review of health inequalities infant mortality PSA target" shows that infant mortality rates are low, it also highlights the disparity between different social groups. Evidence shows that services need to be targeted at those most in need, particularly the most vulnerable, whilst also improving ways of working across organisations and sectors, such as welfare advice, housing and children's centres.

  8.3  Local Area Agreements are important in meeting health inequality targets. These policies require local government to improve the health of local people, co-ordinate local service delivery and create strong partnerships with other stakeholder organisations. We support the joint appointments of Directors of Public Health and expect that these appointments will help to ensure that Local Area Agreements are implemented across health and local authorities. Despite these roles being relatively new we are confident that once they have been evaluated they will support greater cross-organisational working.

9.0  Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

  9.1  While the Health Profile of England 2007 showed progress in some areas towards reducing health inequalities it is clear that there are still significant improvements to be made. Regional health inequalities still exist, rates of obesity, diabetes and alcohol related hospital admissions are rising, deaths from chronic liver disease and cirrhosis have risen markedly, and despite declining teenage pregnancy rates, the UK also has the highest proportion of births to women under twenty compared to any other Western European countries.[79] It is therefore unlikely that many of the Public Service Agreement targets set by the Department of Health will be met.

  9.2  Rising obesity levels also appear to be prevalent amongst children as well as adults. Whilst we support efforts to improve information to consumers about the food that they purchase, more needs to be done with industry to improve dietary information, reduce saturated fats and sugars in food and address the advertising of fast food, snacks and sweet drinks. In addition to this, more emphasis should be placed on actively encouraging exercise by providing safe play facilities and open space in communities.

January 2008

72   Oakley, A. et al, "Social Support and Pregnancy Outcome" British Journal of Obstetrics and Gynaecology, 97 (1990). Back

73   Mencap, "Death by indifference" (2007). Back

74   Dumper, Hildergard, Is it safe here? Refugee women's experiences in the UK, RefugeeAction: London (www.refugee-action.org.uk/information/documents/researchreport.pdf), 2002 Back

75   www.dwp.gov.uk/asd/tabtool.dwptabulation Back

76   www.breastfeedingmanifesto.org.uk Back

77   The Chatterbox initiative in Plymouth is an excellent example of a nurse-led innovation. The initiative was set-up by health visitors who identified a gap in services for young families who wanted to meet up for advice and support. Back

78   Department of Health, December 2007. Back

79   Department of Health, October 2007. Back