“Despairing. Gobsmacking. Claptrap” – PAC verdict on health inequalities

Sweating in front of a parliamentary select committee doesn’t get much worse than hearing your record described as  “Despairing …. Gobsmacking … Claptrap”.  That’s how Public Accounts Committee Chair Margaret Hodge MP (Labour-Barking) flayed civil servants – and by implication their ministerial masters from her own party -  for years of failure to tackle health inequalities after their election in 1997.

The committee’s conclusions  from Tacking Inequalities in life expectancy in areas with the worst health and deprivation are below. We agree with them and have given our quick response after each one.

1.  The gap in life expectancy between people in deprived areas and the general population has continued to widen.

MAC says: There is still not enough urgency or focus for action to stop this.  Resources are incoherently deployed with blunt performance measures. To much is directed “to” people and not enough done “with” them to enable individuals and communities to improve their own health status.

2.  The Department was too slow to develop an evidence base of cost-effective interventions.

MAC says: The policy and practice disconnect between knowing what interventions would make a difference and failure to provide the right tools and incentives to use them has to stop.   Commissioners at whatever level have to be accountable for making closing inequalities part of their core work.

3.  The Department has failed adequately to address GP shortages in areas of highest need.

MAC says: Good primary care in deprived areas won’t happen automatically.  It needs inspired people properly resourced and led. Just having “more GPs” is simplistic; it needs the right primary skill mix deployed in the right place doing the right things.

4.  Many GPs fail to focus their attention sufficiently on the more deprived people registered with their practices.

MAC says: Improving lives and hence the health of the neediest people is tough work.  It has to be contractually linked to success or it won’t get done.  As well as the existing contractors, we would like to see “chambers” of community nurses and nurse specialists out in the community holding contracts to address health needs of individuals and groups such as those with long term conditions.   Health promotion may work best outside of the NHS itself, so more social enterprise and community development initiatives are needed which make use of local people themselves to drive changes.  Extra effort and greater imagination needs to go into finding ways of involving the so-called “hard to reach” as these are the very people who are least likely to be included in screening and other sorts of disease prevention and the ones most likely to need it.  GPs tell us they get fed up being shouted at by the loudest shouters: an understandable reaction.  But if they want to hear those who don’t shout at all they need to listen very carefully.

5.  Two thirds of primary care trusts in areas with the highest deprivation still do not receive the money due to them under the Department’s funding formula.

MAC says: Addressing inequalities means investment in the right things and disinvestment from the wrong ones across all sectors, not just health. A “total place” budget is needed which brings together health, local government and the third sector.  And give local people a real voice in how it should be spent.  This means much more than having a few local councillors on committees.

6.  The NHS spends around 4 per cent of its funding on prevention, although individual commissioners’ spending on prevention is not readily identifiable.

MAC says: Public health efforts have to be just as cost effective and transparent as everything else.  Don’t do things that are ineffective and develop the community to be able to take control of its own health.  The forthcoming Public Health White Paper and the creation of a National Public Health Service are initiatives with promise.  Local Health and Wellbeing Boards must recognise that the NHS itself has little leverage on prevention and improvements will come in education, housing, transport, environment and other related areas.

7.  Addressing health inequalities is a complex challenge requiring sustained and targeted action.

MAC says: Sustained leadership and development are essential; one offs don’t work and outcomes take time to show.  ”Mainstreaming” good practice is more difficult than people think. Realistic indicators of progress are lacking.  Besides  clinical  and managerial leadership,  we need the biggest missing ingredient of all – local lay leadership.  Volunteering is only part of this; empowering lay people as leaders with professional skills is a challenge that can’t be ducked any longer.

8.  The Department is not clear why some areas are performing better than others, or of the extent of the NHS’ contribution in tackling health inequalities.

MAC says: Industrial strength accountability across health and local government  - and to communities themselves – for improving health inequalities has to happen.  Outcome measures need to be clear and easy to understand. Access to local and comparative data, as promised in Mr Lansley’s “information revolution” will help this so long as people can access, understand and act upon this resource.

GPs shared the rack

Mandarins weren’t the only ones on the rack. GPs too were excoriated for ignoring simple things that could reduce yawning gaps in pooor health and mortality between areas of deprivation and affluence.  The Committee wondered if they were distracted with maximising their income through a new contract that largely ignored anything meaningful about health inequalities.

The Lancet weighed in on this point this week in a blistering editorial  “Claptrap from the UK’s Department of Health” It praised Ms Hodge’s committee for exposing a tale of decrepitude at every level of the health system.

“Where were the doctors” The Lancet thundered?  Surely the medical profession had a responsibility for the health of the population  and for delivering the best services possible in return for their status and high level of reward from the public purse?   The editorialist answered his own question thus -

Members of Hodge’s committee tried to find out why doctors had been so reluctant to address inequalities themselves. There are some simple and proven interventions that, if implemented evenly across the population, would go a long way to reduce inequalities in health—notably, smoking cessation and the treatment of high blood pressure and raised cholesterol.

But doctors did not respond to the clear public and political call to take action on inequalities (and nor did the media). Instead, they sought to massively increase their salaries in a new general practitioner (GP) contract in 2005, one that itself was empty of commitment to reduce inequalities.

People died because of this professional failure. The negotiators of that GP contract, together with the Department of Health, share a responsibility for those deaths.

Lessons for tomorrow

This is stern language from both the PAC and one of the country’s most respected medical journals.  There could hardly be a stronger lesson for the future vision of a liberated NHS in England with GPs holding most of the commissioning money.

Our hope is that Mr Lansley’s team will take Ms Hodge’s committee’s report to bed with them and require the new NHS Commissioning Board to be word perfect in learning and applying its lessons when they negotiate the new GP contract and commission primary care.

They won’t get a second chance and nor should they.

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