1. Doran Technical Brilliance, Social Blindness? Health Inequalities and the NHS Tim Doran University of Manchester NPCRDC Health Inequalities and the NHS HERON Meeting, 7 April 2011

2. Doran NPCRDC Topics: o A bit of history o Health inequalities in the UK o The role of the NHS in tackling health inequalities Health Inequalities and the NHS

3. NPCRDC Doctors and health inequalities Health inequalities Inequalities in the UK Role of the NHS Rudolph Virchow Omnis cellula e cellula Virchow’s node Virchow’s triad ‘embolism’ ‘leukaemia’ Cellular pathology Anthropology Autopsy History Health Inequalities and the NHS

4. NPCRDC Typhus outbreak, Upper Silesia 1848 Health inequalities Inequalities in the UK Role of the NHS History “The absolute separation of school and church is more necessary in Upper Silesia than anywhere.” “Artificial epidemics... are indicators of defects in political and social organization, and affect predominately those classes that do not participate in the advantages of the culture.” “The answer to preventing outbreaks in Upper Silesia is quite simple: education, freedom and welfare.” Health Inequalities and the NHS

5. Inequalities in mortality Standardised mortality ratios, 1921 - 1925 Pritchard J, “Mortality Mosaics” 2008 The twentieth century Recent history Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

6. Inequalities in mortality Standardised mortality ratios, 2001 - 2005 Pritchard J, “Mortality Mosaics” 2008 The twentieth century Recent history Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

7. Doran et al, BMJ 2004;328:1043-5. Geographical and social inequalities Health inequalities Inequalities in the UK Role of the NHS The twentieth century Recent history Health Inequalities and the NHS

8. Dahlgren G, Policies and Strategies to Promote Social Equity in Health Determinants of health Role of health care services Health inequalities Inequalities in the UK Role of the NHS Contribution of clinical medicine Clinical intervention Health Inequalities and the NHS

9. 1) Royal College of GPs 2008; 2) British Medical Association 2009 Tackling health inequalities Role of health care services Contribution of clinical medicine Clinical intervention “GPs have an important role in reducing health inequalities. With unrivalled access to the heart of communities, we can influence the health inequalities agenda as practitioners, commissioners and community leaders.” [1] “It’s not my job to solve the problem. My job is to solve the patient’s problem, not society’s problem. [Health] outcomes… are actually nothing to do with the health service but to do with wider society.” [2] Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

10. Benzeval et al Tackling Inequalities in Health 1995 Tackling health inequalities Role of health care services Contribution of clinical medicine Clinical intervention Ensure that resources are distributed between areas in proportion to their relative needs Respond appropriately to the health care needs of different social groups Promote a wider approach to developing healthy public policies Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

11. SEPHO, Atlas of Coronary Heart Disease 2006 Meeting clinical need Coronary heart disease mortality and coronary revascularisation Revascularisation rates, 2004/5CHD mortality rates, 2002-04 Health inequalities Inequalities in the UK Role of the NHS Contribution of clinical medicine Clinical intervention Health Inequalities and the NHS

12. Access to care Distribution of GPs Benzeval M, Judge K. JPHM 1996; 18: 33-40 Patients per GP Contribution of clinical medicine Clinical intervention Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

13. Access to care Distribution of GPs, 1996 Benzeval M, Judge K. JPHM 1996; 18: 33-40 Patients per GPUndersupply (percentage) Contribution of clinical medicine Clinical intervention Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

14. Primary Care Aggressive case-finding and careful audit o Glyncorrwg, population of ~ 1,800 ranked bottom 5% for area deprivation (64% SCV) o Health centre, 1964 – 1987: screening for BP, smoking, cholesterol, diabetes, PEFR, BMI, alcoholism fully computerised in 1988 o Outcomes: Glyncorrwg SMR 0.95 Gwynfi SMR 1.60 Tudor Hart J et al, British Medical Journal 1991; 302: 1509-13 Contribution of clinical medicine Clinical intervention Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

15. The Quality and Outcomes Framework Achievement by area deprivation quintile Doran et al. Lancet 2008; 372: 728-736. 2004-05 2005-062006-07 Reported achievement Contribution of clinical medicine Clinical intervention Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

16. Recommendations for clinicians/medical educators Contribution of clinical medicine Clinical intervention RCP How Doctors can Close the Gap 2010 Consider the impact of their practice on health inequalities Harness the power of student advocacy and action on the social determinants of health Generate and share information on best practice concerning the social determinants of health Highlight and advocate policies and programmes that benefit the health of socially disadvantaged groups Work with public health specialist teams and local authorities to develop programmes to promote and protect people’s health and tackle health inequalities Health inequalities Inequalities in the UK Role of the NHS Health Inequalities and the NHS

17. o Health inequalities Are responsible for millions of years of lost life Are not inevitable Are socially determined Require sustained political interventions NPCRDC Summary o The role of the NHS Is fundamental to tackling health inequalities Identifying and meeting need Provide access & continuity Primary and secondary prevention Health Inequalities and the NHS

18. Further information: tim.doran@manchester.ac.uk