Tackling health inequalities is a challenge faced by policy makers and health practitioners This assignment will critically discuss how Coronary Heart Disease (CHD) may be tackled, drawing on the current evidence based thinking and social policies on tackling health inequalities. Over the past 30 years, there have been a number of strategies proposed to tackle health inequalities. They have all largely focused on improving the health of the most disadvantaged groups, reducing the gap between the best and worst off and improving health across the whole gradient. (Graham, 2004) The above will also be discussed below.
The World health Organisation (WHO) 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. Targets in England also aim 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 for Health, 1999). Similar targets have been set up in Wales, Scotland and Ireland with the aim of tackling health inequalities (Graham, 2004).
A health gradient approach in tackling health inequalities directs attention to the systematic differences in life expectancy and living standard associated with people's position in the socio economic hierarchy (Graham, 2004). Tackling health inequalities needs to focus on the causes of health inequality and health damaging behaviours associated with peoples' unequal position in the socio- economic hierarchy (Graham, 2004). Improving the health of the poor groups and improving their position relative to other groups is an important strategy in reducing the socio-economic gradient. However, the Department of Health (DOH) (2002a) emphasises that to meet national targets and make progress on tackling health inequalities interventions must reach more than the most disadvantaged. Marmot (2010) also points out focusing solely on the most disadvantaged will not reduce health inequalities Graham (2004) adds 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.
The White Paper: Saving Lives: Our Healthier Nation, published in July 1999, aimed to improve the health of the population as a whole, improve the health of the worst off in society and narrow the health gap (DOH, 1999a). Narrowing the gap between the worse and better off, requires absolute improvement, raising the health of lower socio- economic groups faster than the higher socio - economic groups (Graham, 2004). However, Graham (2004) points out that in a society where overall rates of health are improving absolute improvement in their health may be insufficient to narrow the gap between the worse and better off. Wagstaff ,Paci and Van Doorslaer,(1991) also add that focusing on the worst off can obscure what is happening to intermediate groups, experiencing poor health consequently compromising health across the socio-economic hierarchy. 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 (DOH, 1999). A budget of £96m was allocated to these programmes, however the White Paper aimed at the population as a whole and didn't set any specific national targets for reducing health inequalities (Shaw et al, 1999).Consequently there was no significant improvement in health inequalities.
Public health policy has been redefined to give more emphasis to tackling systematic health differences of advantaged and disadvantaged groups (Graham, 2004). Improving the health of the worst off and reducing poverty is the government's main target in tackling 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 (1980) and the Acheson Report (1999) recommended prioritising the health of families with children, reducing income inequalities and improving standards of poor households (Acheson, 1998). Reducing child poverty and improving circumstances of children would have long term effects on reducing health inequalities (Acheson, 1999). The government set targets to reduce Child poverty by half, by 2010 and eradicate child poverty by 2020 (DOH, 1999). The 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 high enough to provide a financial security in old age, however the current government have increased the retirement age to 67 years, which may increase income inequalities in the elderly people. The older one gets the less hours they work earning less income.
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. Good working conditions can reduce the risk of developing CHD. However, getting people into low paid, insecure and health damaging work will increase the exposure to poor health therefore increasing health inequalities. For individuals such as the permanently sick or house bound, employment may not be the solution out of poverty. Furthermore, it would be impossible to reduce unemployment if there are no jobs available (WHO, 2008). In April 1999, the government also introduced the "National minimal wage", this policy was aiming at reducing "in work poverty" and decrease the number of individuals dependant on social security (DOH, 1999).
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). 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 benefits to support families' with children. However with the current government and its initiatives to cut cost, this may not be achievable.
Furthermore, physical, social and emotional health is important in child development and these have an influence on education, occupational opportunities and life chances (Marmot, 2010). Marmot (2010) suggests that giving every child the best start in life is crucial in tackling health inequalities across the gradient. He recommended increasing the proportion of overall expenditure to the early years and ensuring that the expenditure is focused progressively across the social gradient. This includes providing good quality in 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 health gap (Bambra et al, 2010)
Quality housing free of cold and damp is a basic need for healthy living. Shaw et al (1999) point out that poverty can be reduced by raising the incomes and standard of living of poor families with children, disabled and elderly people. The Central and Local government should increase the value of welfare benefits and pensions and improve social infrastructures including social housing and public services (Shaw et al, 1999). Marmot (2010) also recommended creating and developing healthy and sustainable places, which will improve social capital thus removing barriers to community participation and action across the social gradient. Authorities should ensure urban planning such as increasing street lights and safe pedestrian walkways in order to improve physical activity. This promotes good physical and psychological well-being and safe behaviours, which are essential for health equality. Furthermore, access to big supermarkets through investment in active transport can improve access to healthier food choices among low income groups. However, improving access to supermarkets and advising people on healthy food will not be effective solutions if the price of fresh fruit and vegetables is high. Having a balanced healthy diet that has low and fat will reduce the risk of CHD (Lindsay and Gaw, 2004). Central government could restrict the food industry on the amount of fat and salt levels put in foods (Shaw et al 1999).
Maintaining physical activity for at least 30mins at a time can reduce risks to CHD. Investing in public services for example leisure centres, play areas for children, physical activity can be promoted. However some of these public services come with a cost. Worrral et al, (1997) points out that there is unequal distribution of health resources as the more health resources go out to the' richer' households than to the poorer households. To improve access to health resources authorities need to conduct regular audits to enable the redirection of resources to the disadvantaged communities.
The government published the New White Paper, Choosing health: Making healthier choices in 2004, which aims to support individuals and promote informed healthier choices especially those in disadvantaged groups (DOH, 2004). However, making choice is difficult to exercise if lacking the resources necessary, particularly the disadvantaged.
Tackling smoking is a key intervention that can rapidly reduce the number of early deaths among CHD incidences. There have been a lot of campaigns and educational programmes encouraging individuals to make healthier choices. These have included preventing people from starting to smoke; smoking cessation especially disadvantaged adults and pregnant smoking women, and protecting non-smokers from tobacco smoke through introducing Smoke free zones (DOH, 2010). And a regulatory control of alcohol consumption such public houses and bars closing early and minimal age limit on alcohol consumption. However, enforcing smoke bans and alcohol regulations are viewed to be effective methods but asking poor people to change risky behaviour when they cannot afford a proper meal or warm clothing and yet use smoking as a means of escape from their plight might not be sufficient enough to reduce health inequalities.
Individuals from worse social circumstances have considerably high level of cardiovascular risk than those ones from better off circumstances (Bambra et al, 2010).Marmot (2010) recommended the need for early detection and prioritising prevention of chronic diseases related to health inequalities across the social gradient. Harkin et al (2010) estimated that an equal uptake of effective primary prevention across all socio economically disadvantage groups can reduce inequalities. However equality in health care services may not be sufficient enough to end health inequalities. The DOH (2000) proposed a national screening programme for all people aged 40-74 to assess their risk of developing heart diseases. The use of statins is another key intervention that can rapidly reduce the number of early deaths among CHD incidences The use of cholesterol lowering drugs is based on an individual's level of risk for future cardio vascular events." 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 and Ebrahim, 1999;1097).
Recently attention has been given to the role of the National Health Service (NHS) in promoting public health and reducing inequalities in health. The NHS aims to develop a systematic approach to treating people at risk from chronic diseases and encouraging more people to adopt a healthy life style (Macintyre, 2000). Part of NHS funding is spent on prevention; however most of the major influences on population health such as poor housing, unemployment and poverty lie outside the NHS. More so, health promotion strategies focusing on individual behaviours such as smoking, diet and exercise are more commonly taken up by those in the affluent societies (Macintyre, 2000). Therefore these intervention need to engage fully the deprived populations otherwise this may widen the health inequalities.
While the health of the population may be improving, policy makers have a considerable duty to inform and develop strategies which can contribute to greater equality in health. Allocation of resources in tackling Coronary heart disease should consider cultural and behavioural lifestyles, material circumstances and, psychosocial pathways within social class and across the gradient. Focusing on the most disadvantaged will not reduce health inequalities dramatically. More so, to reduce the stepwise social gradient in health targets should aim at bringing levels of the lowest socio economic groups closer to the national average standard.