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A roadmap for health equity and social justice?

On 30 April 2024, BMJ Leader published this blog by myself, MaryAnn Ferreux, Durka Dougall, and Randeep Kaur Kular.


Since 2010 there has been a steady stream of legislation, policy initiatives and reports, all intended (in some cases purporting) to tackle health inequalities – which are by definition unfair and avoidable, causing immense damage not only to many of our citizens but to the economy and social fabric of the country too.  In the words of Michael Marmot:


The UK is the sick man of Europe. Since 2010, improvements in healthy life expectancy have stalled, health inequalities have been increasing and health for people living in the most deprived areas has been getting worse. The country has been struggling with three big challenges: a decade of austerity, the Covid-19 pandemic and a cost-of-living crisis. Each of these has exposed a grim fact: Britain is an unhealthy place to be poor, even relatively poor. https://www.theguardian.com/commentisfree/2023/apr/24/labour-wes-streeting-nhs-britain-europe

The causes are multiple and crucially they extend well beyond what the NHS can deliver. From the cradle to the grave our lives are influenced decisively by the three pillars of social injustice – unfair distribution of wealth, unequal opportunity, and a failure to recognise privilege. People experience them for no reason other than other people choosing not to act to prevent them.


These injustices are institutionally baked into our lives from cradle to grave- in maternity, in early years, in school and college, in housing, in transport, justice, employment (and unemployment), environment and of course, access to care within the NHS. Scarcity reduces intellectual bandwidth https://www.theguardian.com/books/2013/aug/23/scarcity-sendhil-mullainathan-eldar-shafir


The imperative to tackle health inequities is a powerful and well-evidenced one. The work of Marmot and the attention by others on the impact of inequalities on specific groups (e.g. BME populations, the poorest communities, disabled citizens for example) or arising from particular circumstances (e.g. Covid) provides the basis for a powerful narrative around the impact on individuals and the wider impact on our economy and society.


Despite this there are multiple obstacles to overcome:

  • A “levelling up” policy that refuses to accept that class, ethnicity, or gender, for example, are crucial determinants for life opportunities.

  • Essential resources in public health and local government that have been hollowed out and deprioritised.

  • Siloed working which frequently undermines addressing health inequities.

  • An NHS funding model that remains overwhelmingly focussed on diagnosis and treatment of illness in secondary care and not on prevention or early intervention in primary and community care.

  • The skills and knowledge essential to being proactive and preventative in population health are in short supply.

  • We still too often victim-blame and refer to minority communities as “hard to reach” instead of “under-served”.

  • There is an absence of sustained inter-sectoral accountability for tackling the root causes of inequality – despite opportunities to learn from experiences internationally where government, healthcare organisations and local authorities are held accountable for delivering culturally safe environments and assessed on their progress towards achieving health equity

  • One example of such an approach is the Australian National Agreement https://www.closingthegap.gov.au/ on losing the gap that embeds real partnership between Aboriginal and Torres Strait Islander peoples and the national , state and territory and local authorities on the design and delivery of policies, programmes and services that affect them., focused on better life outcomes.  It acknowledges that to close the gap, it is necessary to take a human-rights based approach to health ensuring that Aboriginal and Torres Straight Islander peoples determine, drive and own the desired outcomes, working alongside all governments as equal partners. https://humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/projects/close-gap-indigenous-health


Despite all these obstacles, there are some positive initiatives across the country, sometimes drawing on the NHS as an anchor institution, that signpost the art of the possible.



But how do we unpick and challenge the biases baked into our society that impede sustained equitable improvement in population health and tackle workforce inequities in the NHS?


We suggest four key actions are needed:


  1. Debiasing systems and processes and not primarily relying on debiasing people.

  2. Board accountability for ensuring equitable health outcomes underpinned by data, scrutiny, and challenge whether through nudges or more direct means.

  3. Strengthening inclusive leadership by making leaders personally responsible for challenging discrimination especially those aspects of discrimination and inequality that prove the hardest to shift – notably race and disability – and promoting leaders who act as active allies, role-modelling the behaviours and attitudes they expect of others.

  4. Ensuring that the workforce and leadership reflects the diverse communities that the NHS serves and takes action to listen to the voices of those impacted by inequity.

Continue reading this article on BMJ Leader.

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