Health Inequalities and Children under One:
The Contribution of Health Services.
Jane Naish
The Context.
The link between health inequalities and social inequalities is well known and accepted. It is also well known that the burden of social inequality and in particular poverty falls disproportionately on children and families with children. This is important in public health terms, not least because of the human distress caused but also because poverty and disadvantage in the early years of childhood is powerfully predictive of disadvantage, poor health status and achievement in adulthood and later life. Families with young children are therefore a particularly important group for interventions that are designed to close the health gap.
The precise mechanisms by which social inequality and poverty impact upon health are far from clear and neither are the policy and practical interventions required to tackle them. However, a key part of the solution is economic. As Shaw et al argue in their review of health inequality and policy: “the most effective way of reducing inequalities in health in Britain is to reduce poverty.” (1999). The means by which income levels are raised and revenue distributed are obviously a matter for political ideology, but also ‘practical politics’ in the sense that governments need to find solutions to problems which are also palatable to the general public and will not damage their chances of re-election.
That discussion is not the business of this paper. Instead, the paper will look at the contribution that health services can make to reducing health inequalities for children under one, with a particular focus on health practice and the work of midwives and health visitors. It will examine how health services can contribute to reducing health inequality in early childhood and what this means for their organisation and delivery. These are complex issues, with a complex history behind them. This paper will outline the background to work on public health and health inequalities within the NHS, assess the evidence on child health inequalities and its implications for health practice, and explore the realities of this practice experienced by those working in disadvantaged communities. It will argue that the health service needs to focus more on the spaces between parents and children, between parents themselves, and between families and their wider communities. The paper concludes by recommending ways in which such a shift might be achieved.
The NHS and Public Health
A Brief History of Public Health in the NHS.
A brief history of the development of public health within the NHS is important in understanding current health work on child health inequality. The origins of public health work in the UK actually lie outside the NHS and a health service model, and were originally concerned with environmental factors such as clean water supplies, and hygiene. Until 1970 health visitors, school nurses and medical officers of health were employed by local authorities, not the NHS. However, a very different emphasis to public health emerged in more recent years. In 1988, the Acheson report refashioned public health work into a professional specialism, moreover a professional medical specialism (Department of Health and Social Security, 1988). The motivation behind this move was concern that public health lay on the margins of NHS activity and lacked power and status within it. The proposed solution to this problem was to create public health departments within the NHS led by public health doctors as Directors of Public Health, whose core work was re-orientated more towards a public health science base including the disciplines of epidemiology, health economics and medical statistics. One result of this development was to fracture the NHS public health workforce. Health visitors and other workers who had traditionally been regarded as public health workers, were also moved into the NHS but located outside the public health department. There was a separation of public health science from public health practice, that is ‘hands on’ work with communities and populations. The emergence of the community paediatric speciality was another important development from the 1970’s to the late 1980’s. Screening individual children in terms of their growth and development became very much the fashion and health visitors and other health workers became consumed within this agenda and the new work it generated.
The NHS reforms that separated purchasing and providing health care services followed in 1989. Public health departments became caught up in the health care commissioning process partly because they were located in health authorities, an agenda not all were enthusiastic about (Levenson, 1997). However commissioning health care services and related work in the evidence and effectiveness of health care provision became a key part of their function. The new emphasis on commissioning health care (as opposed to commissioning for health) together with the establishment of an exclusive model of public health based on science and mandatory medical leadership further isolated and separated the public health function and workforce. Health care commissioners also began to raise questions about the effectiveness of child health screening. Whilst these questions were certainly valid, they led many to conclude (to varying degrees) that health visiting was not an effective, particularly a cost effective, service since it had largely become based around child health screening (rather than broader public health work). Many health authorities subsequently reduced the number of their health visitors. Cambridgeshire health authority for example, cut most of its health visiting workforce.
The 1990’s and early 2000s have been characterised by challenges to the dominance of medicine over public health work. This has come from the ranks of public health managers, academics and scientists who undertake equivalent work to public health doctors but without commensurate pay, status or career opportunities. They have proved a powerful lobby. In the newly reorganised NHS, Director of Public Health posts in primary care trusts are now open to non-medical appointees. There has also been a recognition of the contribution and role that other health service workers make to public health. Important though these developments have been, they have not yet changed or sufficiently challenged the hierarchy of public health in which the science based end of the continuum still dominates.
How central is public health in today's NHS? The current government has clearly recognised the existence of health inequalities (rather than health variations) and there have been several initiatives around health inequalities and the health service, not least the setting of national health inequality targets. However, public health and health inequalities work are far from central let alone a priority agenda for the NHS. That is not to say that health inequality and child poverty are not governmental priorities, to be achieved for example by economic or fiscal policies. It is more that the government does not appear to see health inequality as a crucial to the NHS's work, as a steady stream of government directives pushing the NHS to focus further and further on health care service provision testify (Appleby and Coote, 2002). Even the national health inequality targets do not have real ‘bite’ compared to key performance indicators such as waiting list targets. Whilst it is true that primary care trusts have been given a mandate to improve public health plus their own director of public health, the enormity of the task they face in both commissioning and providing services is likely to push public health down the agenda, at least for the moment.
The NHS and Health Inequalities.
Whilst many of the underlying determinants of health are beyond the remit of the NHS, there is still much that can be done to tackle health inequalities. The inverse care law, where the poor and socially deprived are more likely to need health care services but less likely to receive them compared to their better off counterparts, has long been recognised (Tudor Hart, 1971). This situation holds true today, both in terms of the acute and community health care sectors (Independent Inquiry into Inequalities in Health, 1998). The number of health visitors in any given area, for example, is not determined according to socio-economic factors or health inequalities data. A health visitor in a leafy suburb of Surrey may well work with the same numbers of families as her counterpart in Tower Hamlets, despite the differences in health inequalities and social deprivation indices. There has no serious attempt to redistribute health care resources and health workers in community settings in order to tackle this problem, even though there is evidence it could benefit families who experience poor health. The NHS has no framework or incentive to do this, despite the recommendations of the Independent Inquiry into Inequalities in Health (1998).
Neither has a consistent attempt been made to assess and monitor the impact of changes in local health service provision or practice on health inequalities, even though this has again been shown to have an effect on health inequalities. For example, 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. Stone illustrates how the ‘Back to Sleep Campaign’ which aimed to reduce the numbers of babies who died as a result of sudden infant death syndrome by placing them on their backs to sleep had the effect of increasing the health gap since proportionately more babies were ‘saved’ in the higher social classes (Stone, 1999). It would of course be unethical to not introduce a measure known to have proven health benefits on this basis. However, monitoring the impact of health interventions (so called ‘health inequality impact assessments’) is an important role for health services, not least because there may be additional and compensatory measures that could be introduced.
Universal and Targeted Approaches.
Targeted approaches are a means of directing services to those who have the most health need, and can be framed in terms of equitable access to services, equitable receipt of services or equitable outcome from services (each has different starting points and implications for how services would be distributed). But using a targeted approach can be problematic. By definition, there need to be criteria within targeted approaches to define which groups are included and excluded from provision. Such decisions are rarely clear cut and those who fall just outside the criteria may have virtually identical needs to those who fall within them. In addition, health inequalities follow a social gradient. It is not just the most disadvantaged who suffer from worse health compared to the most advantaged people in society: those in the middle bands also have poorer health, albeit not to the same degree (Evans, 2002). Therefore focussing effort only on the poorest sections of the population provides an incomplete strategy for tackling health inequalities across the board.
Targeted approaches can also have the disadvantage of stigmatising families, labelling them as “needy” or “different”. Some people do not like to use services if they perceive them to be associated with such problems or needs. There has been considerable discussion about whether to keep health visiting a universal service available to all or to target it on those in greatest need (Elkan et al, 2000). However these debates are often confused. Universal and targeted services have sometimes been portrayed as polar opposites when it is quite possible to run both at the same time. For instance it is possible to have a core and universal service where everyone receives a number of inputs, such as home visits, wshilt combining this with a top up approach targetted on particular individuals or communities in greatest need.
There are of course problems associated with a targeted work which need to be acknowledged. However, if we want to ensure health services play their full role in tackling health inequalities then a more targeted approach must be an option. If we want to more effectively tackle inequalities during children's early years we need to adjust the number of health visitors and midwives according to socio-economic deprivation indices, even though defiing precistly how these services should be targeted and at whom will inevitably raise difficult questions.
Public Health: A Site of Multiple Meanings.
The term public health has multiple meanings both within and outside the health service. It can be used to describe a function or intervention; to indicate an organisational structure such as a public health department; to encapsulate a philosophy that is generally based on social justice; or to indicate a way of thinking about an issue or problem. There is not a shared language of public health and discussion about public health work is often problematic because people are quite literally talking about different entities and different starting points within them. There is also a hierarchy of meaning within the term public health. Public health science largely dominates and takes precedence over the voice of public health practice. For example the efforts of practitioners to demonstrate health need can be disparaged on the basis of epidemiological validity (such as small sample size) or lack of research rigour. This partly reflects the status and power of professional groups allied to “science” and “practice” (as described above) but also the dominance scientific over other forms of knowledge. There are limitations to both science and practice. Public health science and practice are part of a continuum and it is only by bringing these two strands together that a complete body of knowledge can be developed and public health evidence and capacity can be built.