I was asked last week to speak a conference which was looking at progress in addressing health inequalities since the influential Marmot review in 2010 which identified six ways to address inequalities:
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure healthy standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill-health prevention.
This got me thinking about the role of social care services and integrated health and care services in addressing inequalities. Here’s what I said:
Since the Marmot review, there has been increasing recognition of the social determinants of health and health inequalities, and increasing recognition of the need to integrate health and care, but there is surprisingly little discussion in the social care sector of how social care and integrated health and care systems could be used to address health inequalities. I think this is perhaps because, despite Prof Marmot’s focus on communities and employment, this issue remains seen as being one of health inequalities, rather than more broadly about health and wellbeing inequalities, so I’d like to consider the concept of wellbeing inequalities and what can be done to address them.
Last year the Care Act made wellbeing social care’s new primary purpose, then defined wellbeing so holistically that services alone cannot hope to achieve it. The concept of wellbeing encompasses not only physical wellbeing, personal dignity and good mental health, but also adequate housing, positive family and community life and like Marmot, the ability to pursue employment and be an active citizen.
To my mind, this holistic idea of health and wellbeing should be the basis not just for social care but for an integrated health and wellbeing system, because we will only successfully integrate health and care services when we ask them to measure themselves against achievement of a unified set of outcomes. This holistic view of what public services should be attempting to achieve is also the only route towards a genuinely preventative system and is inherent in the Marmot recommendations.
So what could we define as ‘wellbeing inequalities’ and what could be done to address them?
The biggest demand challenge public services face is the quarter of the population now living with a long term condition. People with long term conditions are at higher risk of failing to achieve wellbeing, but this is not an inevitable consequence of their medical condition: it is just as much linked to low rates of employment, poor housing and high rates of isolation and loneliness. In other words, we need to embed the social model of disability and illness, rather than the medical model, in all of our thinking about health and wellbeing outcomes and inequalities.
Traditional services are essential for mitigating some of the most severe consequences of wellbeing inequalities but they cannot create equality of wellbeing. Nor are conventional public health approaches such as information campaigns, education and screening likely to make any impact. So what does make a difference?
Many wellbeing inequalities are closely related to the amount of social capital a person, family or community has. Social capital or community capacity refer primarily to the number and quality of relationships between people.
There is often an assumption that lower income communities necessarily lack social capital, because some of the elements of positive community life are absent or reduced, such as good housing, functioning local facilities, enough leisure time and disposable income to engage in community activities and the ability to influence local decision makers. This is only partially true: often community capacity and leadership in low income communities are harder or less attractive for statutory agencies to recognise and engage with: hidden rather than absent. Agencies tend to remain focused primarily on the problems and needs of ‘deprived’ communities, and to draw their staff and leadership from outside those communities, which can result in them trying to impose solutions which fail to engage with and build on the potential of local capacity and leadership. This means they may instead undermine existing community capacity or replace fragile networks of support with professionally-led imitations, which rely upon funding which is short term and unsustainable. In other words they can inadvertently exacerbate health and wellbeing inequalities through ignoring the crucial role of social capital.
Interventions like Shared Lives and Homeshare by contrast take an assets or capabilities based approach to building health and wellbeing, which addresses the whole concept of wellbeing as defined by the Care Act, and which looks for and builds upon the capacity and potential of individuals, families and communities to build good lives and good places. Shared Lives schemes provide people from all walks of life and backgrounds with the training, support, back up and payment they need to share their own homes and family life with an adult who needs support. David, who has a learning disability and a history of homelessness and petty offending is one of 12,000 people living as part of a supportive household where his personal care needs are met, but more importantly, he feels he belongs and has something valuable to offer – he is not simply a passive recipient of care. His Shared Lives carer has been able to involve her own networks of family, friends and neighbours in helping David to live well, and they feel their own lives are enriched by the experience. Whilst Shared Lives needs the infrastructure, regulation and payments required to support people with substantial needs, other approaches for wider groups of people can be lighter touch such as time banks, community enterprise development, Homeshare and SilverLine which helps older people volunteer from their own homes as befrienders for other isolated older people.
Extensive research has established the links between wellbeing inequalities such as the high rates of isolation amongst older people and health inequalities: loneliness is as bad for your health as smoking, for instance.
So as well as promoting new capabilities-based approaches, we also need to start measuring the success of every health and care service not only on whether it can meet its primary medical or support goals, but also on the extent to which it impacts positively or negatively on the connections, informal support networks, confidence and resilience of individuals and families. Challenging health and care services in this way would not necessarily increase their costs, but would force them to take a more holistic approach to addressing health and wellbeing, which would often only be possible if they formed new partnerships, not only with other services but with citizens and families themselves.
This integrated approach to addressing health and wellbeing inequalities, already championed by people like Professor Jane South of Public Health England, is for me the next phase in moving from our current system focused on illness treatment and crisis response, to a preventative and community-based national health and wellbeing service.