Monday, 15 August 2005
When trying to reduce health inequalities, don’t forget the people
Despite the commitment in the NHS Plan, a “status report” this month on the programme for action to reduce health inequalities published in 2003 shows that the health gap between rich and poor isn’t closing, it’s actually widening. If this trend continues, Government is on course to miss its key targets to reduce health inequalities by 2010.
The effort going into tackling health inequalities thus far has been about devising and delivering more and better targeted services. “Health trainers” to help people in the most deprived parts of England develop better lifestyles is the latest manifestation. “Healthy living centres” and the “5 a day” campaign to increase consumption of fruit and vegetables are high profile projects too.
Two worrying findings
It all sounds great, but two findings in particular from the latest review of progress might lead one to question this approach:
- Fruit and vegetable consumption – "since 2001 there has been no improvement in fruit and vegetable consumption for the most disadvantaged groups and no significant narrowing of the gap."
- Smoking – "there has been a reduction in smoking prevalence among all adults since 1998 (including a slight reduction in manual groups), but no significant narrowing of the gap in smoking prevalence between manual groups and other groups; there is a strong social gradient in smoking prevalence among pregnant women."
More people in less healthy communities who start eating better and not smoking are two pretty obvious “street level” health indicators that things might be improving. If these basic things aren’t getting better, we should be worried about the rest.
Community engagement – rhetoric or reality?
The well-intentioned programme to reduce the health gap brims with language about assessing needs, delivering targeted interventions at local level and evaluating their impact. The Programme for Action laudably identifies "engaging communities and individuals" as one of the four main themes.
It’s odd, therefore, that there is nothing of substance in the latest review of progress about engagement and community development. Ethnicity is also acknowledged as a strong factor in health inequalities, but it was not systematically studied in this report. Another odd aspect.
The review does contain a brief mention of the engagement theme on page 53 (of an 85 page review):
"projects such as the Engaging Communities Learning Network (ECLN) provide a conduit for sharing this learning. The Network helps PCTs engage with local people and front-line staff and the results of some of this learning have been recently published in Stories that can change your life: communities challenging health inequalities. Adopting a systematic approach, the lessons in these stories underline what works and how this can help other needs in the country. They also show how such work can be mainstreamed into wider public services."
True enough. The Engaging Communities Learning Network and its good practice publications were inspiring. Note the past tense. They are hardly going to remain robust tools for change since NatPact, which hosted them, was closed down at the end of March and the end of the ECLN followed in April. All this work has been subsumed into the “NHS Networks” websites for those who want to seek it out.
“Bottom up” development needed
In the light of the “status report” in tackling health inequalities, one has to ask “where is the real commitment, much less the resourcing and action, that needs to go behind a bottom up community development strategy to reduce the health gap between communities?”
Perhaps it’s indicative of what’s wrong that the phrase "community development" does not occur anywhere in the entire report. Networks are fine, but have a limited shelf life. They are just tools to help build lasting capacity within communities to improve their own health.
Doing things "to" people to improve their health rather than building up a sustainable community strategy to achieve things "with" people seems to have yielded little.
Perhaps we shouldn’t be surprised, therefore, that so many people still won’t eat their greens before they light up!
Tackling Health Inequalities: Status Report on the Programme for Action
Stories that can Change your Life: communities challenging health inequalities