The UKPHA is an independent, UK-wide voluntary association, which through our membership brings together individuals and organisations from all sectors, who share a common commitment to promoting the public's health.

  As a multidisciplinary organisation we seek to promote the development of healthy public policy at all levels of government and across all sectors. We act as an information platform and aim to support those working in public health both professionally and in a voluntary capacity.

  Our mission states that through our members, activities and co-operation with others, we aim to be a unifying and powerful voice for the public's health and wellbeing in the UK, focusing on the need to eliminate inequalities in health, promote sustainable development and combat anti-health forces.

UKPHA Priorities

  Our three key priorities concerning public health are:

—  Combating health inequalities—working for a fairer, more equitable and healthier society.

—  Promoting sustainable development—ensuring healthy environments for future generations.

—  Challenging anti-health forces—promoting health-sustaining production, consumption and employment; collaborating with businesses to promote socially responsible and healthy products and services.

UKPHA Definition of Public Health

  At the UKPHA we believe that public health:

—  is an approach that focuses on the health and well being of a society and the most effective means of protecting and improving it

—  encompasses the science, art and politics of preventing illness and disease and promoting health and well being

—  addresses the root causes of illness and disease, including the interacting social, environmental, biological and psychological dimensions, as well as the provision of effective health services

—  addresses inequalities, injustices and denials of human rights, which frequently explain large variations in health locally, nationally and globally

—  works effectively through partnerships that cut across professional and organisational boundaries and seeks to eliminate avoidable distinctions

—  relies upon evidence, judgement and skills and promotes the participation of the populations who are themselves the subject of policy and action.

EXECUTIVE SUMMARY

  From the above it can be seen that the UKPHA stance is that the NHS can make only a limited contribution to the reduction of health inequalities. However, a large proportion of our membership work within the NHS and strive to ensure that they tackle the social, environmental and economic determinants of health in their everyday practice. Their involvement in the UKPHA Special Interest Groups offers further opportunity to develop policy and practice in tackling health inequalities. This submission therefore has been developed in close consultation with our SIGs and we have included examples based upon the Pharmacy SIG and the Health Visiting SIG.(See below)

  Our basic message is that the NHS has a significant role to play in reducing health inequalities but to do so to maximum effectiveness must:

—  radically revise its culture,

—  develop and value collaborative working relationships with communities, local authorities and other local agencies/organisations

—  ensure that services at the frontline are adequately resourced and valued

—  actively promote and sponsor research which identifies changes/innovations and interventions necessary to combat health inequalities

BRIEF INTRODUCTION

  The NHS can and should contribute to a reduction in health inequalities as part of their core mission, but there are barriers (outlined below) to it performing this function.

  Whilst the number of staff in the NHS has risen dramatically with the increased funding over the last 10 years, the number of public health staff and those concerned with prevention has fallen. This says something specific about the culture of the NHS, which is focused on treatment and cure, with a higher status afforded to those concerned with the "headline grabbing" interventions, such as those in intensive care, acute surgery and the working age population.

The NHS is heavily focused on illness and disease, and many would claim this as its proper function. However, the causes of health inequalities differ from the causes of disease. If the NHS only focuses on treatment, or even prevention of specific diseases, it will not succeed in reducing health inequalities

FACTUAL INFORMATION

  There is a great deal of evidence about how health inequalities are manifest, but far less information about which interventions help to reduce them.

  The Independent Review on Health Inequalities conducted by Sir Donald Acheson in 1999 identified that a focus on supporting mothers and babies/young children would be the best way to reduce health inequalities in the long. The only professional group named in that report was health visitors, as they had a track record of providing this form of support (see example below).

  The structural, anti-health forces that contribute to health inequalities can only be changed in the long term (ie, over generations), leading to difficulties in identifying measures for progress so short term. This is not impossible, but would require investment in research of a different kind to that used to evidence disease-focused interventions.

  We should differentiate upstream and downstream policy on tackling health inequalities. The NHS contribution tends to focus on downstream—because it is picking up the problems in physical illness and psychological distress which we might attribute to the structure of UK societies, socio economic issues.

BARRIERS

Failures in collaborative working

  Although it is acknowledged that the NHS cannot, alone, reduce health inequalities. Its track record in collaborating with other agencies is not good, except where others are seen to relieve the burden from the NHS; eg, working with social services to reduce bed occupancy of older people.

  The advent of children's centres, designed to improve collaboration for all working with the early years, has provided an opportunity. There are some very good examples of collaboration, with NHS, education and voluntary sector all working together, particularly where there were Sure Start Local Programmes. However, the majority are inadequately developed and focused on childcare and children over the age of 3 years, which both misses the most important period of development as far as health inequalities is concerned, and also fails to engage with NHS/health visiting services.

  The excess winter mortality in the UK (25,000 extra deaths per annum) and unquantified excess morbidity amongst vulnerable groups, due to fuel poverty, could be dramatically reduced if frontline health care workers and other agencies involved with the delivery of energy efficiency and home heating improvements worked together, referring, sharing information and following through to ensure rapid and efficient remediation.

  Similarly, more joined up working by the NHS with local authorities and the voluntary sector could make a significant reduction to the rising obesity levels which are strongly correlated with social disadvantage. Community involvement and participation, access to local fresh produce, the availability of green space, safe walking and cycling etc could all be enhanced if there were systematic working between NHS staff and their counterparts in local authorities and the voluntary sector.

  Health Action Zones and Sure Start have both provided excellent examples of how to begin to engage communities and the evidence is beginning to come through to show early successes. Large changes in health inequalities cannot been seen in less than a generation. However, because they were both conceived as projects separate from the mainstream, they absorbed capacity and skills away from the NHS. Also, providing them with separate funding and management sent a message to the NHS that this was not their core business.

NHS Culture

  NHS culture is focused on illness and disease is a barrier to reducing health inequalities:

—  The efficient management of waiting lists and winter pressures etc is a testimony to the focusing and skill of NHS, but a different mindset is needed for the management and reduction of health inequalities.

—  It is possible and likely that health inequalities will widen unless there is a parallel emphasis on prevention, which means enhancing access and expanding services to incorporate a community focus.

—  The prevailing culture is one where mental health services are seen largely as the "poor relation". Yet meaningful improvement in these services could significantly reduce the prison population and inequalities in employment opportunities, particularly for minority ethnic groups

—  The achievements and incentives culture (QOF) is certainly not a true preventative model and will never help to address inequalities. Analysis shows that it is those GP practices in the more affluent areas which are reaching their targets.

Lack of evidence

  The medical model of disease treatment informs views about what constitutes good research, and this can help with understanding some approaches to health inequalities. However, randomised controlled trials are not always feasible as a mechanism for showing how best to improve health inequalities, or how to organise services so they become more accessible to disadvantaged groups etc.

  There is not only a shortage of research, but also a shortage of research funds available to focus on health inequalities. Tenders are generally assessed on how closely they conform to the medical ideal of the RCT

  Lack of RCT evidence is cited as a reason for employing, or not employing particular approaches to reducing health inequalities

COMBATING HEALTH INEQUALITIES THROUGH THE NHS

Example 1:  Health visiting services

  The outcomes from health visiting are largely seen in areas other than the NHS, yet health visitors are employed/commissioned by the NHS. The need for their services is poorly recognised, because it is wholly focused on prevention, and the need for support of parents with young children is not often seen as a priority. In keeping with the NHS culture of prioritising the "acute" and "dramatic," focusing on established problems, the "Nurse Family Partnership" approach is being rolled out to a small minority of disadvantaged families. Although this is a very positive programme for the few who receive it, it will reach far too few needy people to affect the statistics of health inequalities across the board. Also, since this appears to be being implemented at the expense of universal services for all parents with young children, it could potentially make inequalities worse.

  Many health visitors and school nurses and their teams working in primary care/community services make an unseen and often unrecorded contribution to inequalities in health. They do this through the universal provision of services and by the advice and support they provide for families, signposting them on to other services, and agencies supporting them to seek help, with housing, education, child care employment etc.

  Practice based commissioning tends to be very acute focused.The focus should be upon community or primary care based commissioning. Re-dressing this balance could help inequalities a great deal. Those nurses who are brave enough to run nurse led primary care services and employ their own GPs—not many as the hurdles are enormous—do help to reduce inequalities and they generally work in under doctored areas or with travellers and other disadvantaged groups

Example 2:  Pharmaceutical services

  There is a marked lack of information and research on pharmacy involvement in tackling health inequalities. However, the white paper Choosing Health through Pharmacy [DH 2005] suggests how the profession can help deliver the government's public health agenda through a ten-year programme of engagement to 2015. It contains examples of good practice to encourage pharmacists to maximise their contribution to improving health and reducing health inequality. It has something to offer pharmacists in all NHS settings, covering community (high street chemists), hospital and primary care pharmacists. In addition, one of its main objectives is to send out a strong message to commissioners of health improvement services (who in the current structures are the real gatekeepers) and to the wider community of public health practitioners and specialists signalling that pharmacy is a willing partner in improving the public health.

The scarce evidence of pharmacy and public health

  A review of the pharmacy practice literature and public health literature shows that community pharmacy has not traditionally been recognised as a key player in the public health movement. Although its core role originates in the safe preparation and dispensing of prescribed and over-the-counter medicines, in more recent times pharmacists have ventured beyond this to develop an "extended role", contributing to health promotion and improvement through providing public information and advice at the community "high street chemist" base. Harding and Taylor (1994) reported that the profession has long struggled with the notion of public health whilst Jesson and Bissell (2006) assert that the profession had failed to grasp the full scope of the emphasis on a new public health agenda and its value base in tackling population health inequality.

  More significantly, when Payne et al [2005] undertook a scoping exercise to measure pharmacy's contribution to tackling health inequalities they observed,

"Most mainstream policy documents on health inequalities and social exclusion from the Department of Health pay little attention to the role of community pharmacies" and concluded " what this review highlights is that there is relatively little to date on the place of pharmacy in the drive to reduce health inequality—and that more should be done in this field" (p6).

  In a context where there is little reliable evidence base for policy tackling health inequalities these resources confirm that there is scant evidence of the role of community pharmacy in the drive to reduce health inequalities.

  It should be noted that Pharmacies and Pharmacists have made a considerable contribution to (downstream) public health lifestyle issues, where services can be combined with a product eg smoking cessation, EHC, diagnostic tests, minor ailments schemes. Such services have been linked with PCT through the new contract or Patient Group Directives (PGD). However, such services are not mainstream and when the funding is pulled the service ceases. So a lot of public health work was stopped when the NHS has funding crisis.

  The multiples, Lloyds Pharmacy, Boots, Moss etc have seen a business opportunity to combine public health advice.. Lloydspharmacy was the first to advocate a social approach and has made more of providing a community based service (its shops are in disadvantaged areas especially West Midlands and moving into Wales). It is not clear what is going on in the Independent owned sector. However, none of this is mapped by deprivation index or population demographic data. It may well be that the multiples have such information but consider it to be competitive advantage data.

  So we don't know to what extent these public health services reduce inequalities or increase them. There have been no research funds available to try and find out

RECOMMENDATIONS FOR ACTION

  Our recommendations are self-evident from the above and we can only repeat what we stated in our summary:

  To maximise its effectiveness in reducing health inequalities the NHS must:

1.  radically revise its culture,

2.  develop and value collaborative working relationships with communities, local authorities and other local agencies/organisations

3.  ensure that services at the frontline are adequately resourced and valued

4.  actively promote and sponsor research which identifies the changes/innovations and interventions effective and necessary to combat health inequalities

January 2008