The NHS was founded on the principle of equality – healthcare being available to everyone based on need and not on the ability to pay. Inclusion of all healthcare providers across the four home nations and in every location – urban or rural, north or south, rich or poor – meant that there were no exclusions. That concept has changed little over the years, but as medical services, developments and expectations have grown beyond recognition the notion of how to fund and deliver all health needs equitably has become increasingly complex.
Inequities became more apparent as the basic health needs of the population were increasingly well addressed; the original model of providing individual episodes of care to treat acute illness and manage chronic disease is no longer applicable. The importance of disease prevention has become key. To be effective this needs to target those at most risk, especially groups that find it hard to engage with healthcare. The use of new technologies may make them even more vulnerable. Prevention also needs adequate resources.
At the beginning of the last decade Marmot provided a strong case for change regarding the social determinants of health inequalities, demonstrating that certain groups have significantly shorter life expectancies, poorer outcomes and more difficulty in accessing the services they need due to social circumstances. His recommendations then included strengthening the role and impact of prevention of ill health. Ten years on life expectancy in the UK has stalled and the health inequalities gap is widening. Also, the chasm between the funding of acute services and that for public health and preventative strategies has grown ever larger meaning that the overall burden of demand continues to rise year on year – a trend that must be halted if progress is to be made.
Health and social care have gradually become inextricably linked. The Academy has long called for an answer to the current underfunding of social care so that resources can be freed up to reduce unnecessary admissions and delayed hospital discharges. The lack of placing equal importance on health and social care is taking its toll at a time when adequate social care for the elderly and young disabled would enable better use of NHS funding and staff in more acute settings as well as providing more effective, and less expensive, care in community settings.
Further areas of inequality that recent work has shone a light on are the differences in importance placed on, and investment in, physical and mental health and the increasing evidence that there are differences between access to care and therefore, outcomes of certain diseases based on patient gender or age. In addition, better use and understanding of routine data have revealed unwarranted variation and hence lack of equality, in processes and services that are evident countrywide varying between location and provider.
There is no doubt that the inequalities in healthcare have been recognised, discussed and some steps have been taken over the past 10 years to address specific areas. As we enter a new decade with increased funding and plans in place to deliver healthcare differently, it is time for further, more effective actions. It is essential that these challenges are met head on, removing barriers and increasing support where indicated at individual and population levels; for all members of society – no exceptions – embracing both health and social care.
The NHS constitution remains clear that resource allocation should be ‘based on clinical need’ and also that services should be ‘available to all’ and not based on social or other circumstances. Individual Medical Colleges and Faculties have been vocal in emphasising and offering solutions where inequities for their individual areas of medicine sit and collectively, as the Academy, we are well placed to work together to reduce inequalities in health.
The Faculty of Public Health today publishes it 2020-2025 Strategy with the vision of ‘better heath for all – leaving no one behind’.
Carrie MacEwen, Chair, Academy
Maggie Rae, President Faculty of Public Health
© 2021 Academy of Medical Royal Colleges.