On Monday I outlined why, if the NHS wants to improve the average performance over the next 10 years in for example cancer survival, the real gains will come from those parts of the population who currently have the worst rates. If you want to make substantial gains in an average you need to shift large numbers who are below average. (It’s the way numbers work). Which means having a resolute focus on those that are currently below the average. Improving outcomes for people that are already doing very well doesn’t provide sufficient improvement in the numbers to substantially shift the average.
That’s why any real ambition in the new long-term plan contract will need to attack current inequalities.
Yesterday I pointed out how the principle of ‘equal access for all’ is being breached every day by a practice that does not concentrate on the most unwell. For example if you are 5 times more likely to smoke in Blackpool than Wokingham we need to provides five times more anti-smoking services in Blackpool to provide equal access for all.
Today I want to develop this further, but in a more radical way.
In order to provide equal access for all it is necessary to provide more of an NHS service in areas where there is more need. Therefore, in an age of prevention and anticipatory medicine it is right to provide more prevention in those areas where there is likely to be higher prevalence in the future.
That means not just matching greater need in one area with greater resource, but also providing extra resource in those areas where there is potentially more need. Waiting for people in poorer areas to have a stroke, and then providing more resources because there are more strokes is a good idea, but a better one would be to provide substantially more stroke prevention services to those who are more likely to have strokes.
Inequality in English society has many dimensions – not just health and healthcare. Last year wealth in the UK went up by £450 billion. Of this, £431 billion was the result of an increase in land values. I don’t know about you dear reader but I don’t own any land and I’m not sure I know many people that do. Land is owned by a very small percentage of British people and last year they garnered nearly all of this increase in wealth for themselves. Other aspects of wealth are unequal. Social mobility has stalled. Housing is unequally distributed and so are educational qualifications.
Given the extent and the levels of inequality in all of these important aspects of life, the very large life expectancy differentials that exist between the poor and the better off are inevitable. If the NHS expects to do something real about inequalities, then it is going to have to do more for people who have less in every other aspect of their lives.
I am NOT saying that the NHS can overcome all these other inequalities on its own. That would be laying a burden on the NHS that it cannot achieve. But I am saying that if we really want greater equality of health outcomes in society then those who have less of all the other aspects of life will need better access to healthcare to compensate.
To put this simply. We believe in equal access for all, but if poorer people are sicker for longer they will receive more healthcare.
But in these days of anticipatory medicine, when we are trying to calculate which people will get certain diseases we need more resources spent on those in areas where they might be.
What might this mean for the NHS Long-term Plan?
Firstly – as outlined on Monday – given that we know how to improve life expectancy in poorer areas – so that it has a trajectory that catches up with the average – we need to pledge to do that. What that means is that people of a certain age in poorer areas need to be provided with many more opportunities to engage with cardiovascular check-ups and ‘stop smoking’ services. This needs imagination and above all persistence. A simple invitation to a cohort of people will not suffice. The NHS in these locations will simply not be working unless all of these people are fully engaged.
Second, the long-term plan will roll out a number of innovations in healthcare and its relationship to the public. In the 10 year roll out of innovation these changes should happen first in those areas where people are the sickest for the longest. If we are to improve cancer survival rates, then let’s do it in those areas where more people are dying of cancer younger. If we are to get back to 18 week waiting times once more, (and this is likely to take some years) then let’s do that in areas where people are poorest and live the shortest lives.
Over the next 10 years the NHS will not create an equal society.
But it can make a start.