The COVID-19 pandemic has devastated communities across the UK.
Death, overwhelmed health systems, families plunged into poverty: all have become familiar themes to us. Throughout all these themes runs one common thread, and that is inequality.
It is perhaps a cliché to say the pandemic has shone a light on health inequalities, but that is exactly what has happened.
We understand so much more about the fatal consequences of successive governments’ failures to address the gaps in healthy life expectancy in this country.
People who were worse off financially and socially had poorer health outcomes before the pandemic and as a result, the virus was able to attack these communities more easily.
That is a lesson we cannot afford to ignore. It may seem strange to talk about drawing anything positive from the pandemic, but COVID-19 has given us an opportunity to build our society back better and fairer. We have learned about what society got wrong, and what it needs to do to make things right.
From 2010 to 2019, increases in life expectancy in the UK slowed, while in other comparable economies life expectancy increased at a faster rate (1).
Compared with countries in the EU, the UK does not feature in the top 10 (2). Between 2010 and 2020, life expectancy slowed the most in the most deprived areas of the country, and in fact stagnated or fell for some groups (3).
Life expectancy in this period fell among the poorest 10% of women in the Yorkshire and Humber region, and in the north-east of England (4).
By 2019, there was a nearly 20-year gap in healthy life expectancy between women living in the richest versus poorest areas of the country (5).
Healthy life expectancy in Scotland has also been decreasing according to latest figures (6). In Wales, it has been calculated that more than a third of years of life lost are related to socioeconomic inequality (7).
In Northern Ireland, while it appears life expectancy rates are no longer decreasing, the rate of respiratory mortality among under 75s in the most deprived areas is three and a half times that in the least deprived (8).
Health inequalities are felt most directly by individuals and communities, but they also place a considerable burden on our health service. One study put the cost of socioeconomic inequality for NHS inpatient hospital services in England alone at £4.8bn a year (9).
It is incredibly difficult for clinicians like me to see in our patients the human cost of worsening health inequalities. The Government must provide the resources to allow the health service the time and space to observe and intervene. Meanwhile, this toolkit will make it easier for doctors to take action. Together, we can make a differenceSheffield GP Krishna Kasaraneni
If health inequalities are the problem, then, what is the solution? It is too often assumed that inequality exists because people smoke too much, drink too much, eat poorly and do not take enough exercise, but it is more complicated than that.
The evidence strongly suggests that people are put on a path of poor wellbeing in early life if exposed to domestic violence, parental mental ill health, family poverty and other adversity (otherwise known as ‘Adverse Childhood Experiences’) (10).
One crucial consequence of these experiences can be growing up feeling less positive about one’s ability to be in control of one’s own health and wellbeing. The root of the problem can therefore be more accurately said to be not the presence of harm but the absence of wellbeing.
How do we create wellbeing? Simply telling people they are damaging their health does little good and can make them more despondent. Experience tells us the best outcomes arise when front line staff develop trusting, supportive relationships with people who are struggling.
Instead of telling people what to do, evidence clearly shows the best approach is to ask firstly what they need and secondly how they can support them in achieving those aims. In short, as doctors we have the chance to lead people back onto the path of wellbeing.
Doctors are close to the problem and the stories of projects we have collected in this toolkit are to give colleagues ideas to try.
I hope that by sharing stories of what works, we can empower you to lead the direction of reducing health inequity from the bottom up. Public health colleagues, by collecting data on successful interventions, can spread the learning further.
This toolkit is intended to support clinicians working across the UK. It is not for laying the responsibility of reducing health inequalities at the feet of busy clinicians.
Neither is this toolkit intended as a replacement for our campaigning at the BMA to ensure UK governments meet their responsibilities to reduce health inequalities.
We cannot make change happen alone. What we can do is to lead the way for other professions and show the importance of small tests of change and the importance of building trust with people living difficult lives.
We have an opportunity for the medical profession to lead the way in fighting inequalities. The section at the end of the toolkit also has resources for medical students, who can make a real impact in their communities.
Wherever you work and whatever your specialty, I hope this toolkit will help support you in any work looking to address health inequalities affecting your patients and communities.
Sir Harry Burns is president of the BMA 2020–21
1) OECD (2020) Life expectancy at birth. ‘Similar economies’ refers to countries in the European Union
2) OECD (2020) Life expectancy at birth. Ranking list is of countries in the European Union plus the United Kingdom
3) Office for National Statistics (ONS) (2021) Health state life expectancies by national deprivation deciles, England: 2017 to 2019
4) Health Foundation (2020) Marmot Report: Ten Years On
5) ONS (2021) Health state life expectancies by national deprivation deciles, England: 2017 to 2019
6) National Records of Scotland (2021) Healthy Life Expectancy in Scotland, 2017-2019
7) Public Health Wales Observatory
8) Department of Health NI (2021) Health Inequalities Annual Report 2021
9) Asaria M, Doran T, Cookson R (2016) The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation
10) UCL Institute of Health Equity (2015) The impact of adverse experiences in the home on the health of children and young people, and inequalities in prevalence and effects