Inequality in health is not a new issue in the United Kingdom. The Beveridge Report in 1942 identified key concerns of disease and poverty that would form the welfare state. The report said that ill-health kept people in a cycle of living in poverty and so a national health service would have a positive impact on the nation. (Pemberton, 2010) Beveridge (1942) believed that there would never be an improvement as a nation until health inequality was noted as an issue. He said that the way to put Britain back on track after the war was "to target the health inequality that existed between the wealthiest and the poorest members of society." Ministers agreed and the welfare state was formed. (Pemberton, 2010). Another key report was published called the Inequalities in health report (Black et al, 1980) this is also known as the Black report. This report contains official statistics showing a gradient of inequality from the richest to the poorest. It highlighted that those in poorer social classes were more vulnerable to heart disease, cancers and strokes and that they died sooner and in greater numbers than those in higher social classes. It also showed that those in poorer classes were more susceptible to infant and child death, (Denny and Earle, 2010.) This highlights how health inequalities between the upper and the lower classes in society are longstanding.
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Despite the Beveridge Report, and the statistics highlighted in the Black Report, there are still health inequalities in the twenty-first century. The latest statistics released from Oxfam (2012) state that 1 in 5 of the UK population live below the official poverty line, and over 13 million people in the UK do not have enough money to live on. The Department Of Health [DOH] (2010) estimate that "up to 202,000 early deaths could be avoided if everyone had the same health opportunities as university graduates."Â In the start of the twenty first century in England, people living in the poorest parts of the country could on average expect to die seven years earlier than people living in more affluent parts, also they could expect to spend far more of their lives with ill health. (DOH, 2010)
In recognition of the health inequalities still prevalent in the United Kingdom in the twenty-first century, the DOH commissioned an independent review by Marmot (2010.) This focused on the impact of wider social aspects of health inequalities such as education, employment and housing. The report suggests that although life expectancy is improving for all social groups on the whole, there is no narrowing of the gap between the life expectancy of social classes - the higher the social class, the higher the life expectancy. (Denny and Earle, 2010)
Poverty can link in with other aspects of health inequality, such as race, gender, disability and age. The Marmot Report recognised that a lot of people who are living in poverty are of black and ethnic races. The report suggests that 44% of the ethnic minority population of England were living in a deprived area. (DOH, 2010) This links in to what Oxfam, (2012) say, "black ethnic minority populations are more likely to be unemployed, have low incomes, report ill-health, and live in the most deprived areas of the country." Oxfam, (2012) also go on to say that women form the majority of those living in poverty and that women haveÂ less power and less influence in decision making than men do.Â Williams (2009) says thatÂ 25 per cent of women are in the lowest income tier and are out of work.. A study by McConkey (2001) showed that people with learning disabilities are less likely to have paid employment and therefore be living in poverty. McConkey interviewed 275 people with learning disabilities and their results show that 42 per cent of the interviewees had unpaid / voluntary jobs, however only 1.5 per cent had paid jobs, despite wanting them. Denny and Earle, (2010) State that older people who are living in poverty are at greater risk of ill health, as they are often isolated and struggle to make their needs known, despite having the greater need for the support. Hart (1971) says that those in need of healthcare obtain the services less frequently than those who have less need. Gillam and Florin (2002) go on to say that those "most at risk of ill health tend to experience the least satisfactory access to the full range of preventive services" calling this the 'inverse prevention law.'
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Denny and Earle (2010) say that the poor may access these services less due to transport issues, or even education as to what the services can offer. Gainsbury (2008) reports that the wealthiest tenth of the population are overfunded by the National Health Service with budgets of medication and hospital care, whereas the poorest tenth of the population are underfunded for these things. This is backed up by a review by Dixon et al, (2003) which shows that hip replacements are 20 per cent less frequent amongst lower social classes, despite the fact that those in a lower social class have a 30 per cent higher need for the surgery.
Health care professionals need to be able to recognise health and social inequalities so that they can respond appropriately. Gillam and Florin (2002) says that there are three levels of interventions from health professionals which can be used to tackle health inequalities. These are individual, organisational and community interventions. Individual interventions can be defined as interventions which take place between an individual health professional and a patient (Gillam and Florin 2002) Organisational interventions deal with the way care is organised and look at the practicality of it to see if interventions are accessible to disadvantaged groups. Community interventions are community development initiatives, such as food banks for people who are living in poverty, and have less access to food. The Trussell Trust (2013) states that "In 2011 food banks fed 128,687 people nationwide. TheÂ rising cost of food and fuel combined with other factors are causing more and more people to go to food banks for help." For individual intervention, it would be the health professional that should raise awareness of these sorts of community interventions to their patients, so that they can access the services. Organisational interventions are schemes such as the 'Healthcare Travel Costs Scheme' which "helps people living in poverty with the cost of travelling to hospital or other NHS premises for NHS-funded treatment or diagnostic test arranged by a doctor or dentist." (NHS,2011)
According to Denny and Earle (2010) Nurses can contribute to tackling health inequalities as they have an important role to play in helping to restore the patient's voice by being mediators and advocates for patients who have encounters with other health care professionals. This links in to the NMC (2008) which says that a nurse must "act as an advocate for those in their care." The The Institute of Health Equity [IHE] (2012) says that advocacy is an important area where health service professionals can positively affect the social determinants of health, and help to create the conditions for individuals to take control over their own lives. Because health professionals are highly trusted, and have a well recognised position in the community, their chances of supporting patients within their social context improves. The IHE (2012) goes on to say that "healthcare professionals require an understanding of the social context of their patients in order to understand their health better."
The IHE (2012) believe that appropriate signposting and referrals to initiatives that can have a positive impact on health and social inequalities should be as "much part of care pathways as referrals to other health services." They go on to say that health care practitioners need to be aware of the services available in the community to which they can refer patients. For example, if a patient / client was living in poverty and struggling for money, a health professional could refer them to the local housing advice centre, or to the job centre or citizens advice bureau for benefits advice to ensure they are receiving the money they are entitled to. The NMC agree with this, and the code (2002) says that nurses must give patients access to "relevant health and social care information and support."
Some people who live in poverty are doing so because they are unaware of what benefits they are entitled to, particularly elderly people. Age UK (2012) highlights statistics of unclaimed benefits that pensioners are entitled to. It says that annually, £5.5billion goes unclaimed by pensioners, on benefits such as housing and council tax benefit, and pension credit. Age Uk claims that approximately 390,000 pensioners do not claim housing benefit each year, making them lose out on approximately £2444 annually. For healthcare professionals who want to get people out of the poverty cycle, it could be useful to know this information so that it could be passed on to patients that come in to contact with them. The IHE (2012) states that this has been trialled in England by placing citizens advice bureaus in General practitioners surgeries, and this has shown to reduce psychological stress of patients.
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Therefore, cross-sector and partnership is key in taking action on the social determinants of health at all levels and both in decision-making and service delivery. It enables support to be much more holistic and ensures that wider issues are recognised and acted upon.