If you travel between the first four stations of London Underground’s Central Line, life expectancy falls by one day per second for those living along the tube. In the Wirral peninsula the life expectancy gap is 10 years, across only seven miles.
Life expectancy is just one indicator of the widening health gap between areas that are wealthy and those that are experiencing deprivation. In the period 2018 to 2020, male life expectancy at birth in the most deprived areas of England was 73.5 years, compared with 83.2 in the least deprived areas. For females, the equivalent estimates were 78.3 years and 86.3, respectively.
Inequality comes at a huge price. In 2010, it was estimated that total treatment costs would be approximately 15% lower in the absence of health inequalities, with an estimated cost to the NHS of £5.5bn. This data did not capture all aspects of health and care utilisation and therefore does not reflect the full extent of costs.
Tackling health inequalities is necessary not only personally for those experiencing disparities but also for economic reasons and the long-term sustainability of our health system.
To understand why health inequalities exist, we can consider the seven domains of deprivation:
1. Income
2. Employmen
3. Education
4. Health
5. Crime
6. Barriers to housing and services
7. Living environment
These domains form the basis of the social and economic determinants of health. Many are associated with the place and community in which we live. Several are important functions of local authorities. By taking a holistic approach to addressing disparities, councils can therefore make positive changes to the determinants of health.
This could be achieved through a health in all policies approach, where the social and economic determinants of health are addressed through policy, including those influencing transport, housing and planning, the environment, education, agriculture, finance, taxation and economic development so that they promote overall health and health equity.
Joined up working between local authorities and health and care system partners will also be central to reducing health inequalities. Councils must be core members of the local integrated care board to ensure a whole-system approach is adopted to tackle inequalities and to draw on the specialist knowledge and skills of colleagues working across services.
As New Local demonstrates in its Community-Powered NHS report, communities have a wealth of knowledge and assets which can strengthen resilience and enable prevention-focused public services, leading to improved health and wellbeing. As Marmot describes this in his 2010 review, the creation and development of healthy and sustainable places and communities as central to tackling health inequalities. One component is enabling people to have greater control over their lives – of creating their own health. In his more recent report, Marmot draws on examples of community agency and control as facilitators for health and wellbeing to demonstrate this.
Local authorities and the Integrated Care Systems should focus on Marmot’s positioning of community empowerment and consider how they can create a culture that enables this.
There is a raft of examples of where local, community-powered approaches to tackling health inequalities are already bearing fruit. In Lancashire, GP Dr Andy Knox recognised that people living six miles apart in Morecambe Bay had a difference in life expectancy of more than 15 years. He worked with the population health team and communities to run initiatives such as working with schools to introduce the physical activity through a ‘daily mile’, healthy eating projects, engaging more widely with communities through co-hosted conversations and using seed funds to draw on community members to introduce choirs and mental health cafes.
Dr Knox is now working to curate a programme of support for primary care clinicians in the Lancashire and South Cumbria region to develop as a leadership community, to build skills for population health including for tackling health inequalities, and to lead improvements in practice.
The wider NHS is also taking stock. Dr Bola Owolabi, who is leading the NHS’s health inequalities work, has set herself the redoubtable challenge of being able to demonstrate, within two to three years, that the health inequalities gap has actually narrowed.
Community power is a key part of this. One of the directly funded projects is through the Core20PLUS approach and specifically the Core20PLUS Connector Programme, which funds integrated care systems and place-based initiatives to recruit, mobilise and support influential community connectors to take practical action to improve health and reduce inequalities in their area.
Tackling health inequalities requires a whole system approach but it is important to recognise that health doesn’t start in health and care systems, it starts in our homes, our neighbourhoods and our communities.
Laura Charlesworth is head of health research at New Local. Laura, Dr Knox and Dr Owolabi are speaking at Stronger Things, which is taking community-powered health as one of its key themes.
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New Local's Stronger Things event at London's Guildhall on 23 May is sold out. For live-streamed keynotes and tailored workshops on system change, race equity and culture change visit: www.newlocal.org.uk/strongerthings2023.
