Policy makers and health practitioners are faced with a challenge trying to tackle health inequalities, these include improving the health of the poor societies, addressing health across the population, through closing the health gaps between those in better off circumstances and the poorest groups. This assignment will critically analyse how CHD Coronary Heart disease may be tackled drawing on the current evidence based thinking and policies on tackling health inequalities.
Over the past 30 years , there have been a number of strategies proposed to tackle health inequalities (Bramba et a 2010)l . They have all largely focused on improving health of the most disadvantaged groups, reducing the gap between the best and worst off and improving health across the whole gradient. (Bramba et al 2010). The WHO ( World health Organisation ) 1999 global strategy of achieving health for all is fundamentally directed towards achieving greater equity in health between and within populations . this implies that all people have an equal opportunity to develop and maintain their health ,through fair and equal access to resources for health. The targets in England recommend to improve the health of the disadvantaged groups and that of the population as a whole and also closing the health gap (Secretary of state ,1999),thus improving health across the whole gradient And similar strategies have been set in Wales, Scotland and Ireland with the aim to tackle health inequalities(Graham 2004).
Graham 2004 points out that goals in the public health policy have been redefined to give more emphasis to tackling systematic health differences of advantages and disadvantaged groups. Wilkinson (1996) suggest that policy makers can reduce the numbers in society experiencing relative deprivation, through a more equal distribution of income, therefore improving the health of the whole population. Reducing the health gradient there is need to focus on the causes of health inequality in the disadvantaged circumstances and health damaging behaviours of the poorest groups. And also the systematic differences in life expectancy ,living standard and lifestyles associated with peoples unequal position in the social economic hierarchy (Graham 2004 pg 123).
DOH (2002a:2) emphasises that to meet national targets and make progress on health inequalities interventions must reach more than the most disadvantaged. Graham (2004) point out that to improve the social gradient, policies need to be associated with absolute improvements in health for all socio-economic groups with a rate of improvement which increases at each step down the socio-economic ladder. Graham 2004 points out that improving the health of lower socio economic groups relative to other groups is an important strategy to reduce the socio-economic gradient.
Wagstaff ,Paci and Van Doorslaer ,(1991) add that in focusing on the worst off ,it can obscure what is happening to intermediate groups who are also doing badly and may compromise health for those at the bottom. Also a health gap approach can underestimate the pervasive effect which socio-economic inequality has on health, not only at the bottom but also across the socio-economic hierarchy (Graham 2004).
A major Independent Inquiry into inequalities in health ( the Acheson report) was set up in July 1998 to summarise inequalities in health and identify areas for development of policies to reduce health inequalities. In the Acheson Inquiry outline 39 recommendations to reduce inequalities in health. ( Shaw et al 1999) acknowledging what the Black report had outlined. The recommendations included priority to be given to health of families with children,reduce income inequalities and improve standards of poor households( Achenson 1998). However ,the Inquiry was criticised as there was no adequate prioritisation among the recommendation. The next health major strategy published after the Acheson report was White Paper Saving Lives : Our Healthier nation, published in July 1999, its aim was to improve the health of the population as a whole, to improve the health of the worst off in society and narrow the health gap (DOH ,1999a). The white Paper set targets to be achieved by 2010 of which included reducing the death rate in people aged 75 years from CHD by at least two firths. A budget of £96m was allocated to these programmes, however the white Paper didn't set any specific national targets for reducing health inequalities (Shaw et al 1999).
Reducing poverty is the government's main target to tackle health inequalities. However, targeted policies may have negative effects on the health of other groups, either in absolute or relative terms. Graham 2004). The black report and the Acheson report recommended reducing child poverty and improving circumstances of children would have long term effects on reducing health in equalities ( Acheson 1999 ).
In April 1999, the government introduced the 1st ever "National minimal wage" to the UK ,this policy was aiming at reducing "in work poverty" and decreasing the number of individuals dependant on social security.Furthermore ,getting the unemployed into jobs across the gradient is another way of tackling poverty. Marmot 2010 argues that jobs need to offer a minimum level of quality ,a decent wage and flexible hours to enable people balance work and family life, that promote heath.This can reduce the risk of CHD. However, getting people off benefits and into low paid, insecure and health damaging work may increase health inequalities. For individuals such as the permanently sick or house bound employment may not be a way out of poverty. ( Shaw et al 1999). And also it would be impossible to reduce unemployment if there are no jobs available. (CSDH 2008).
Shaw et al (1999) point out that poverty can be reduced by raising the standard of living and incomes of poor families with children, disabled and elderly people. The central and local government should increasing the value of welfare benefits and pensions and improve public services and social housing ( Shaw et al 1999).There is need to raise awareness of physical activity for example access to gyms .Maintaining physical activity for at least 30mins at a time can reduce risks to CHD. However some of these public services come with a cost. Worrral et al (1997 ;198) have noted that there is unequal distribution of health resources as the more health resources go out to the' richer' households than to the poorer households. ( Shaw et al 1999). Shaw et al (1999) suggested that the authorities could perform regular equity audits and redirect services to the 'poorest ' communities not adequately receiving healthcare
The government published the New White paper Choosing health: Making healthier choices.(2004 ); which aims to support individuals and promote informed healthier choices especially those in disadvantaged group ( DOH 2004). However , making choice is difficult to exercise if lacking the material resources necessary,particularly the disadvantaged.
Effective treatments and care should be targeted and available to those in need, providers should maintain high standards of care ( Davey Smith et al (2000). However equity in health care services may not be sufficient enough to end health inequalities. Individuals from worse social circumstances have considerably high level of cardiovascular risk than those one from better off circumstances ( Davey smith et al 2000).In July 2008 ,DOH proposed a national screening programme for all people aged 40-74 to ass their risk of developing heart diseases.
Tackling smoking and increase in the use of statins are the two key interventions that can rapidly reduce the number of early deaths in disadvantaged groups. There have been a lot of campaigns and educational programmes to prevent people from starting to smoke ,help smokers quit, and to protect non-smokers from tobacco smoke. Aiming at disadvantaged adults that smoke, pregnant smoking women i.e. smoking cessation. The guidelines for targeting the use of cholesterol lowering drugs are based on an individual's level of risk for future cardio-vascular events. Morrison et al 1997 suggest that allocation of resources for reduction of coronary mortality should take account of social class differences and relative potential effect of primary and secondary prevention. If everyone in the UK aged 45- 74 with clinical evidence of CHD were treated with statins for five years, about 22,000 deaths and major clinical events would be avoided(Davey smith et al 2000 page no.)
Deprivation during utero and childhood has lifelong consequences in adulthood life. It is important that all pregnant women are able to afford an adequate diet and have a continuum of care from pre- pregnancy and through pregnancy (WHO ,2005b).However research indicates that current maternity allowance is insufficient to achieve this (Bradshaw ,1993).Shaw et al 1999 suggested that maternity allowances should be increased ,especially for women dependent on income support or low paid jobs. Also to increase additional benefits increased to support families' with children.(Shaw et al 1999)However with the current government and its initiatives to cut costs this may not be achievable. Furthermore, physical, social and emotional health are important in child development and these have an influence on education, occupational opportunities, life chances and health. Grantham-McGregor et al ,2007). Marmot (20100 pointed out , giving every child the best start in life is crucial to reducing health inequalities across the life course.He recommended to increase the proportion of overall expenditure to the early years and ensure that the expenditure is focused progressively across the social gradient. This includes providing good quality early years education and childcare proportionately across the gradient. However , educational and other individual-based approaches tend to be taken up disproportionately by the more affluent which tend to widen the inequalities ( Bambra et al 2010 )
Elderly people are more likely to be diagnosed with CHD, and if in poverty this can worsen the condition. The State Retirement Pension needs to be increased as its too low (Castle and Townsend 1996), However the current government have increased the retirement age to 67 ,which may increase inequalities in the elderly people.
The policy makers need to ensure urban planning as it promotes health and safe behaviours . Access to quality housing and sanitation are basic needs for healthy living.(Shaw 2004). Authorities should ensure that access to basic goods thus promoting good physical and psychological well being which are essential for health equity. This can be through investment in active transport accessing big supermarkets thus Improving availability of and access to healthier food choices among low income groups. Having a balanced health diet that has low and saturated fat will reduce the risk of CHD .They should also put up regulatory control of a number of alcohol outlets even though there is an age limit on alcohol consumption.(shaw et al 1999) In marmot review recommended creating and develop healthy and sustainable places and communities. The aim was to improve social capital and reduce social isolation thus removing barriers to community participation and action across the social gradient.
Harkin et al estimated that an equal uptake of effective primary prevention across all socio economically disadvantage groups can reduce inequalities. Attention has been recently been given to the role of the NHS in promoting public health and reducing inequalities in health through the modernising the NHS. The aim of the modernisation action aimed to develop a systematic approach to treating people at risk from chronic diseases, encouraging more people to adopt a healthy life style (Macintyre 2000). Mormat review recommended the need for early detection and prioritising prevention and of chronic disease that are strongly related to health inequalities along the social gradient . Part of NHS funding is spent on prevention ,however most of the major influences such as poor housing, unemployment, poverty on population health lie outside the NHS( Macintyre 2000). More so ,health promotion strategies focusing on individual behaviours such as smoking ,diet and exercise are more commonly taken up by those with better personal and local resources (Macintyre 2000). Therefore these intervention need to engage fully the deprived populations otherwise this may widen the health inequalities.
Policy-makers need to be aware of health inequalities and how they are patterned, if they are to inform ,develop and deliver strategies which can contribute to greater equality in health . Focusing solely on the most disadvantaged will not reduce inequalities sufficiently . To reduce the stepwise of the social gradient in health ,actions must be universal aiming to bring levels of health in the poorest groups closer to the national average standard.