Health Select Committee Inquiry into the contribution of the NHS to reducing health inequalities
Response from the British Medical Association
January 2008
The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 139,000.
Executive Summary
The extent to which the NHS can contribute to reducing health inequalities should be viewed in the context of evident widening inequalities in wealth and other related socio-economic inequalities.
Some recent and ongoing policy initiatives in the NHS may lead to increasing health inequalities. The Government’s ‘patient choice’ initiative is an example of this.
The NHS as the largest employer in the country has a role to directly and indirectly have an impact on positively reducing health inequalities through employment practice as well as service provision.
GP services also have a role in reducing health inequalities but this can only be part of a wider approach that needs to be seen in the context of efforts elsewhere to address broader inequalities.
The Quality and Outcomes Framework (QOF) contributes to a reduction of health inequality by encouraging a uniform standard of care across all practices and across many disease areas. QOF has also allowed the collection of a significant clinical evidence base that can help to inform wider debate on health inequalities.
In order for Practice Based Commissioning (PBC) to fulfil its potential, GPs need to be given a genuine opportunity to make commissioning decisions that are supported, not led by managers, and adequate resources need to be made available to enable GPs to engage properly with the PBC process.
In general, the BMA believes that General Medical Services (GMS) and Personal Medical Services (PMS) practices offer the best option for all patients, not just those in better-off areas of towns and cities. The BMA remains very concerned that new Alternative Provider Medical Services (APMS) practices may end up delivering a potentially second-class service to areas of the country that already have significant health inequalities.
The effectiveness of public health services is reliant on the availability of an appropriately trained, public health workforce and at present the future viability of this workforce is at risk.
In order to improve the effectiveness of public health services at reducing health inequalities, it is crucial that public health programmes are enabled to cut across different sectors and engage local communities.
The BMA would question whether Health Action Zones (HAZ) and Sure Start have yet proven to be effective (and cost effective) on a wide-scale, whilst acknowledging that some individual, local schemes have been shown to be of value.
The level of success of NHS organisations at co-ordinating activities with other organisations has generally been very low and therefore, much more works needs to be undertaken if reliable, integrated schemes are to successfully and consistently reduce health inequalities.
There needs to be much greater joined-up thinking in government and there should be consideration given to appointing a minister at cabinet level whose responsibility is the health of the public and who would oversee work in every government department to try and facilitate this.
What is the extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas e.g. taxation, employment, housing, education and local government?
1. The NHS has been, and will continue to be, expected to play a central role in addressing the issue of health inequalities and is presently subject to a set of ambitious targets focused on this objective. Nevertheless, the current efforts of the NHS must be set against the backdrop of a wide-range of evidence that suggests that inequalities in health continued to widen in the 1980s and 1990s, and that, sadly, the expectation is that such inequalities are unlikely to have been reduced by a great margin, if at all, by 2010. Of particular importance is the fact that increasing health inequalities seemingly reflect trends in income inequality, which, in a similar manner to health inequalities have increased in the latter part of the 20th century. reference 1 reference 2
2. Consequently, the extent to which the NHS can contribute to reducing health inequalities should be viewed in the context of evident widening inequalities in wealth and other related socio-economic inequalities. Ultimately, despite recent favourable economic circumstances, and the introduction of initiatives such as the national minimum wage, new deal, and tax credits, it is only with greater redistributive policies targeted at poverty and income inequalities that we might expect to see a sustained reduction in health inequalities. Until such a time, the NHS will continue to strive to address a limited range of the causes of health inequalities and their effects but can do little more than ameliorate many of the wider impacts of socio-economic inequalities on the health of the UK population.
3. A further concern is that some recent and ongoing policy initiatives in the NHS may lead to increasing inequalities, the ‘patient choice’ initiative being a case in point. The former Secretary of State for Health, Patricia Hewitt, stated that “choice is important… because – far from entrenching inequality – it will help us create a more equal society.” reference 3 It is noteworthy that many of the key strategic documents on health inequalities produced by the Government in recent years do not promote the patient choice agenda, nor advocate any form of increased choice – rather the documents tend to encourage uniformity, for example with the introduction of National Service Frameworks. references 4 reference 5. Our concern is further illustrated by a joint study by RAND Europe, the King's Fund and City University which found that patients possessing formal educational qualifications were more likely to choose hospitals with higher standards of clinical performance as providers of their treatment. However, patients without formal educational qualifications placed significantly less importance on increases in clinical quality above an ‘average’ level. reference 6 In effect, this research suggests that offering patients greater choice risks widening health inequalities.
4. It should also be appreciated that, as one third of inequalities in health are work-related, occupational health services (including occupational psychology) have an important role to play but such services are neither mandatory nor publicly-provided and do not form part of the NHS as currently constituted.
5. The NHS is in a unique position as the largest employer in the country to directly and indirectly have an impact on positively reducing health inequalities through employment practice as well as service provision. As an employer the NHS should proactively engage with inequalities of opportunities still experienced by individuals from minority groups within the NHS, including those with disabilities, from ethnic minorities and lesbian, gay, bisexual and/or transgender individuals. Although some work has been started the lack of standardised full diversity monitoring of staff and that lack of commitment to a fully engaged approach to diversity has created a hierarchy of agendas in trusts which further disadvantages some minorities. Even though the BMA does not support quotas or positive discrimination, the NHS could contribute substantially to reducing inequalities relating to employment through transparent universal monitoring of staff and staff progression to illustrate the effectiveness of interventions in the workplace to tackle discrimination and promote equity of opportunity.
6. Furthermore as an employer of over 1 million staff, the NHS must proactively engage in promoting health and preventing disease for its own workforce. The lack of funding or incentives to address workplace health issues and promote a holistic supportive workplace has led to the NHS being criticised for a lack of engagement on issues such as domestic violence and mental health.
How might the distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities?
7. GP services do have a role to play in reducing health inequalities, although we would stress that this can only be as a part of a wider approach and must be seen in the context of the efforts required elsewhere to address broader inequalities, as noted above.
8. Continuity of care and the ongoing trust of patients are critical to the work of GPs, particularly when it comes to discussing with patients many of the wider and less tangible lifestyle issues that affect health inequalities. We therefore believe it is essential that continuity of care is preserved. We are concerned that many recent initiatives in Primary Care, such as the introduction of APMS contracts and the move towards more centralised polyclinics, particularly when combined with the freeze in GP practices’ GMS global sum funding over the past two years, could damage this continuity of care.
9. The Quality and Outcomes Framework (QOF) rewards practices where they can demonstrate that they are giving patients the best possible evidence-based treatments in named disease categories. Over the three years that the QOF has been in existence the national prevalence rate of certain diseases has gone up, demonstrating that the QOF is encouraging greater case finding and identifying more patients with chronic diseases. We believe that, by encouraging a uniform standard of care across all practices and across many disease areas (some of which will be higher among the lower social economic strata of society) the QOF contributes to a reduction of health inequality in healthcare.
10. The Adjusted Disease Prevalence Factor (ADPF) used in QOF currently involves calculating payments in relation to disease prevalence. At the time the QOF was negotiated the ADPF was introduced with a 5% lower end cut-off and a square rooting calculation. The 5% cut-off was to protect and compensate smaller practices. All practices will incur significant fixed costs in identifying morbidity and establishing quality systems and the smaller the practice, the higher these costs will be proportionally. The square rooting transformation was introduced initially so that practices would not face large financial swings should some patients with a specific disease leave their practice and alter their disease prevalence. However, over time it has been recognised that the ADPF has unnecessarily protected practices with very low disease prevalence and failed to fully reward practices with a high disease prevalence. In general the highest levels of disease prevalence are found in the poorest areas. There is now an increasing desire amongst GPs and the political negotiating parties to resolve these inequalities and use a True Disease Prevalence Factor. The BMA’s General Practitioners Committee (GPC) is currently in discussions with NHS Employers as to the viability of moving from an Adjusted Disease Prevalence Factor to a True Disease Prevalence Factor.
11. Additionally, the introduction of QOF has allowed the collection of a significant clinical evidence base that can help to inform the wider debate on health inequalities.
12. Practice Based Commissioning (PBC) also has the potential to positively affect health inequalities by virtue of the close relationship between GPs and their patient populations, allowing them to identify real needs and structure services that address these needs and result in improved health outcomes. In the current climate, PBC is only really able to focus on demand and resource management and so is not realising its full potential. We would also stress that PBC is primarily about commissioning secondary care services, rather than primary care services, which are commissioned by Primary Care Organisations. In order for PBC to fulfil its potential, GPs need to be given a genuine opportunity to make commissioning decisions that are supported, not led by managers, and adequate resources need to be made available to enable GPs to engage properly with the PBC process.
13. Following recommendations made in the Next Stage Review interim report and subsequent guidelines on procurement issued to Primary Care Organisations, we are concerned by the Department of Health’s insistence on the establishment of so many new GP practices under the Alternative Provider Medical Services (APMS) contractual route, a policy which appears to overlook and undervalue the strengths of the traditional independent contractor model delivered through the GMS and PMS route. Private organisations holding APMS contracts employ a salaried or locum staffing model, akin to that of existing Primary Care Trust Medical Services (PCTMS) practices where the turnover of employed doctors is often high, the running costs are higher than GMS or PMS and QOF scores are lower. As we believe that, in general, GMS and PMS practices offer the best option for all patients, not just those in better-off areas of towns and cities, we remain very concerned that these new APMS practices may end up delivering a potentially second-class service to areas of the country that already have significant health inequalities.
14. The commitment to invest solely in new primary care services, rather than improving existing services and/or infrastructures we believe is short-sighted and will not provide value for money. We would wish to see some of this funding going towards GP premises development, allowing for practice expansion. Funding extensions to existing practice premises would allow those practices to increase their list size, improve the level of service and provide a wider range of services to their patients.
15. We are acutely aware that many of the areas with the poorest health outcomes are those which are under-doctored. We would therefore support measures to improve recruitment and retention of GPs in these areas.
What is the level of effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; AND which interventions are most cost-effective?
16. The effectiveness of public health services, with particular regard to reducing health inequalities, has been hindered by the continued reorganisation of the NHS that has characterised recent policy initiatives. Public health professionals have been particularly affected and this has compounded a trend which has resulted in significant numbers of senior public health posts being lost over the past 3-4 years reference 7 Clearly, the effectiveness of public health services is reliant on the availaibility of an appropriately trained, public health workforce and at present the future viability of this workforce is at risk.
17. In order to improve the effectiveness of public health services at reducing health inequalities it is crucial that public health programmes are enabled to cut across different sectors and engage local communities. These services must be implemented such that they are regarded as integral to the mainstream delivery of health services. This approach will require PCTs to become much more adept at fulfilling their public health engagement role and will necessitate the efficient use of the capacity of the public health workforce. A vital element of this strategy would be an increased emphasis on public health in performance management in PCTs. To this end we are concerned that PCTs are not statutorily required to have a Director of Public Health (DPH), and local authorities are not required to have a DPH at all. We would support making this mandatory for local authorities and PCTs, although they could make a joint appointment where their boundaries are coterminous. NHS Trusts (including Foundation Trusts) should also be required to have a public health structure with an appropriate relationship with the DPH of their lead commissioner.
18. Policies to influence the lifestyles people choose need to be tackled on a range of levels – mass media advertising, targeted social marketing, brief interventions by primary care professionals, support for individuals who have decided to make a change, community development and community action to tackle cultural obstacles to healthier choices, and steps to make healthier choices easy to make. (There is, for example, no point encouraging walking and cycling in the absence of attractive walking networks and safe cycle networks or promoting salt reduction if it is impossible to obtain low salt processed food).
19. It is not a question of which of these work. None of them work well in the absence of the others – as integrated programmes they do work. The NHS is the appropriate provider of many parts of this chain but the whole chain will fail if there is a failure of the external interventions in areas outside the health service such as education, housing, transport and so on.
Have specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective?
20. The principal of reducing the effects of persistent disadvantage that underpins the rationale for both Health Action Zones (HAZ) and Sure Start is commendable and the BMA is naturally supportive of efforts to address inequality and social exclusion. However, we would question whether either of these initiatives has yet proven to be effective (and cost-effective) on a wide-scale, whilst acknowledging that some individual, local schemes have shown to be of value reference 8 The national evaluation of action by HAZs to tackle health inequalities suggests that their direct impact on health inequalities was minimal and highlighted the uncertainty concerning the longevity of the HAZ initiatives, exacerbated by continual shifts in national policy, as a key factor that reduced HAZs’ ability to influence local policies. reference 9
21. Nevertheless, in considering the relative success of such initiatives one must take into account the size and nature of the task in front of them. HAZs and Sure Start have been tasked not only with addressing the effects of deep-rooted socio-economic inequalities but have been expected to do so through the development of complex partnership coalitions of multiple interests at a time when the NHS has been the subject of significant organisational change and financial pressures. Certainly, an evaluation of these schemes’ progress must be sympathetic to this context, if not to those who have engendered it.
22. It is, therefore, perhaps unrealistic to expect early demonstrable progress to have been made and only fair to note that without more effective measures to reduce socio-economic inequalities, the chances of such schemes significantly reducing health inequalities will remain notably inhibited.
What has been the level of success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; AND what incentives can be provided to ensure these organisations improve care?
23. It is our experience that the level of success of NHS organisations at co-ordinating activities with other organisations has generally been very low. Consequently, much more work needs to be undertaken in this area if reliable, integrated schemes are to successfully and consistently reduce health inequalities. To achieve this it is vital that more schemes that try to provide joined-up, co-ordinated help in this area are adequately piloted.
24. Some positive examples, however, do exist. The Children's Trust has ensured better co-ordination of work with the local authority and other agencies working with children and young people to create tangible change and address inequalities in a more coherent manner. Similarly, the joint-appointment of directors of public health has tangible differences to the working of other partner agencies, especially the local authority sector, in addressing health inequalities.
What is the level of effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meets its Public Service Agreement targets for reducing inequalities?
25. In recognition of the fact that many of the causes of health inequalities relate to other policy areas, e.g. taxation, employment, housing, transport, big business, education and local government, the BMA welcomes the Department of Health’s undertaking to co-ordinate its work with other government departments in order to meet a number of its Public Service Agreement targets. Indeed, it is imperative that the understanding that health inequalities are greatly influenced by wider determinants of health, founded in socio-economic forces, is entrenched across government.
26. The example of the Public Service Agreement (PSA) on obesity, published in 2004, is a case in point. This target is jointly owned by the Department of Health, Department for Education and Skills and the Department for Culture, Media and Sport. However, without a detailed evaluation of the progress towards these targets, and of the process of co-ordination undertaken to achieve said targets, at this time it is not possible to reliably judge the level of effectiveness of the Department of Health in this area.
27. Just as the Treasury has an overarching role in relation to ensuring prosperity, we believe that government needs to establish an overarching function to ensure improving health. The Department of Health has an overwhelming preoccupation with health services and has interpreted the role of the Minister for Public Health primarily as directed towards medical interventions for prevention. This must change if the Department of Health is to continue to fulfil the lead role on the health of the people. Certainly, if we are to achieve the Wanless fully-engaged scenario reference 10 there needs to be much greater joined-up thinking in government and there should be consideration given to appointing a minister at cabinet level whose responsibility is the health of the public and who would oversee work in every government department to try to and facilitate this.
28. Other alternatives could also be considered. For example, the promotion of health could be effectively linked with other key issues such as sustainability and action to adapt to climate change in a Department of Public Health, the Environment and Social Policy. Or health could be made a major element of Public Service Agreements and the Minister of Public Health could be located in the Treasury. Any of these arrangements would work if there was a determination to have an overarching commitment to health and would fail if there was not. This commitment needs to be led from the top by a Prime Minister prepared to say, as Disraeli said, “the health of the people is the first concern of Government”.
29. One reason we have supported the idea of greater independence for the NHS is so that the Department may spend more time on its public health responsibilities. If there were to be such a reduction in micromanagement and more devolution the element of the Department concerned with NHS matters could be significantly reduced in size. The Department’s remit could then shift to concentrate largely on public health matters and the tackling health of inequalities with much greater attention paid to its remit involving social care.
Is the Government likely to meet its Public Service Agreement targets in respect of health inequalities?
30. No. Most areas are behind the trajectories needed as a result of the persistent restructuring of the NHS and the lack of investment in the public health workforce.
References
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2 - Lakin C. The effects of taxes and benefits on household income, 2002-2003. Economic Trends 2004;607: 39-84.
3 - Hewitt P. The Nation’s Health and Social Change. Discussion Paper, New Health Network, September 2005.
4 - Acheson D (Chair). Independent inquiry into inequalities in health: Report. The Stationary Office, London, 1998.,
5 - Department of Health. Tackling health inequalities: A Programme for Action. Department of Health Publications London, 2003.
6 - Burge, P., Devlin, N., Appleby, J., Gallo, F., Nason, E., and Ling, T. Understanding Patients’ Choices at the Point of Referral, Working Paper, May 2006, Rand Europe.
7 - The Specialist Public Health Workforce in the UK 2005 Survey: ‘A Report for the Board of the Faculty of Public Health March 2006'.
8 - National Evaluation of Sure Start (NESS). Early Impacts of Sure Start Local Programmes on Children and Families, November 2005. HMSO.
9 - Benzeval,M (2003) The Final Report of the Tackling Inequalities in Health Module. London: Queen Mary, University of London.
10 - Wanless, D. (2002) Securing our future health: taking a long-term view. London: HM Treasury.