Shivani Sen
Policy and Research AnalystIn the first of two features discussing the Levelling Up Commission inquiry session on preventative care and health inequalities, policy institute Curia looks at why the system needs reform.
The Levelling Up Commission held its first virtual inquiry sessions of 2023. The session was chaired by Director of the NHS Transformation Unit, Janet Budd and the focus was on reducing inequalities through the health and social care system and how this sector intertwines with the levelling up agenda.
The online discussion was split into two sections. In the first hour, Janet was joined by three experts in the field of prevention, health management, and health inequalities. Panellists included Chief Economist at CIPFA, Jeffrey Matsu, Director of Communities and Health at Bristol City Council, Christina Gray and Director of Public Health at Blackburn and Darwen Council, Abdul Razaq.
Throughout the session, Budd tackled all three panellists with a series of complicated and thought-provoking questions on the topics mentioned above with the ultimate aim of finding some vital solutions and recommendations to ensure that health inequalities narrow.
The role of prevention in health inequalities
The first question that was put to the panel was about the importance of preventative measures in healthcare. Gray believed that prevention has to be โforensic, informed and purposefulโ, as there is a danger of people throwing the term around without any substance.
She added: โYou have to do the leg work of researching the inequality you are talking about at which level of the system and then decide on what the intervention is. Afterwards, youโve then got to monitor the intervention to find whether it is working and whether there have been any unintended consequences.
“However, if we look at rural authorities, which on a wider scale look like they have few inequalities, on a granular level then we find clusters of extreme poverty.”
Christina Gray, Director of Communities and Health, Bristol City Council
โIntegrated Care Systems are THE new opportunity. That is whatโs being presented to us, and it will allow us to work at pace and at scale. The good thing about these systems is that they should open up more secondary and primary interventions.โ
Speaking about examples of preventative measures, Razaq said:
โThere are some good examples in the North East of England where Integrated Care Systems have invested in tobacco control. NHS money and local authority money has been combined to try and make history to reach the target of only 5% of the population being smoker by 2030.โ
Health inequalities at a local level
One thing that all three panellists seemed to agree on was the importance of focusing on tackling health inequalities within local communities.
Research has suggested that taking a regional overview of inequalities helps to target resources at an appropriate local level, improving outcomes amongst disadvantaged communities.
Expanding on this, Gray said:
โThe levelling up agenda has been focused on a national scale which means the Government has been looking at levelling up entire regions rather than taking a more granular approach. However, if we look at rural authorities, which on a wider scale look like they have few inequalities, on a granular level then we find clusters of extreme poverty.
โIโm in a care system of three authorities and some are bigger than the others so itโs important for Integrated Care Systems to work with their local directors of public health, who really understand this granularity. It shouldn’t be a trade-off between national inequalities vs local inequalities, it really has to be both.โ
Matsu was in full agreement with Christina and spoke about how he believed better outcomes can be achieved at a local level:
โItโs about making sure that we have that level of granular understanding of whatโs happening in neighbourhood services such as schools and criminal justice systems. How are these services being delivered at a local level because they cascade over time and have detrimental health impacts.
โTo improve outcomes at a local level, we need to improve incentives to invest in prevention. If organisations donโt have the incentive to help each other, then itโs going to be difficult to reach our targets.โ
Ensuring that funding goes to the right places
A major concern that has followed the levelling up agenda around since its inception is the idea that funding has often gone to the โwrong placesโ. These concerns are also prevalent in the healthcare sector, with Matsu citing issues with data as a major contributing factor:
โThe difficult thing is that a lot of data around health inequalities is backwards looking but preventative investment is forward-looking. We need to make sure that we are investing in the right places that are going to lead to impact for a number of years but itโs difficult to do that with backwards-looking data.
โAs a non-negotiable, we should be targeting more investment in areas where outcomes are poor and if we can identify these areas via other metrics, not just income and wealth, then even better. It requires looking forward and this is what weโre trying to achieve.โ
Promoting healthier choices in deprived areas
There is a line of argument that suggests individuals should be responsible for making healthy choices for themselves. However, as Gray and Razaq rightly pointed out within the inquiry session, this is an unfair line of thought that suggests everyone has equal opportunities in terms of education and income. Gray said:
โMy position is that individual behaviours including choices are actually constrained by wider social, economic, and environmental conditions. Itโs important to take that position because otherwise, you treat everyone as if they have equal opportunities and it becomes an issue of individual responsibility which isnโt right.
โIn my local area, we have decided to disinvest in traditional weight management services such as Weight Watchers. Instead, we are pushing more behavioural interventions. We are working with BeezeeBodies โ a group that works with communities by providing them with healthy living courses for adults and children in a way that works for them.
โAdditionally, we have worked with a local Somali women’s group after they raised concerns about a particular road in Bristol that had several fast food outlets. We worked with them and trading standards to go into those outlets to bring about change.โ
Razaq offered his support to Christina and added his thoughts on individualisation when it comes to health decisions:
โIโm fully with Christina on the debate around individualisation. Not everyone has the same income levels, literacy levels, numeracy levels or digital literacy levels. There are access barriers to certain healthy choices, and this is highly relevant to the levelling up agenda.
โWe are doing a lot of work on numeracy in my local area to make that our population can understand better how to budget better, which in turn can help them to make healthier choices.โ
Final thought
There is no doubt that slow action to tackle preventative health increases inequalities and is a primary cause of poorer outcomes. The Governmentโs flagship levelling up policy to improve life chances is being seriously undermined by a failure to place a priority on prevention.
In addition to the points already raised, the first session of the Levelling Up Commission inquiry session highlighted that intergenerational disadvantage leads to wider health inequalities and leads to poorer outcomes for patients and citizens in general.
It was refreshing to hear how mental health was given parity in the discussion, with panellists explaining that the pandemic of stress and mental health issues cause poorer outcomes.
In the second feature reviewing the recommendations of the two inquiry sessions, this meeting provided much evidence as to why the system must be reformed to drive down inequalities to improve outcomes.
To find out more about the Levelling Up Commission, contact Shivani Sen or visit the Curia website.