2 Public health need and practice
People who enjoy a lifetime of advantage are likely to live longer, healthier lives than those who experience disadvantage (Graham and Power 2004; Kawachi and Kennedy 1997; Wilkinson 1996. Yet despite increased prosperity and reductions in mortality among some population groups, CVD, other smoking-related diseases and smoking are still more prevalent among lower socioeconomic and certain ethnic groups compared with the general population.
Since 1995–97 circulatory diseases have become more prevalent, in relative terms, among disadvantaged groups. For example, in 2004–2006, 44 more people per 100,000 (aged under 75) died from circulatory disease in the most deprived fifth of local authority districts than in the least deprived areas. In relative terms, this means the death rate from circulatory disease was 71% higher in the most deprived areas compared with the least deprived areas (DH 2008a).
Since 1998 there has been no significant change in smoking prevalence among adults in manual groups compared to non-manual groups in absolute terms (and some signs of a widening in the gap in relative terms). In 2006 in Britain, smoking prevalence was twice as high among unskilled workers than among professionals (33% and 16% respectively among routine-and-manual and managerial-and-professional groups respectively [Office for National Statistics 2007]).
Factors such as poor living conditions, lower educational achievement and behaviours which damage health (such as smoking) lead to a greater than average risk of premature death, greater morbidity and lower life expectancy People in lower socioeconomic groups are more likely to adopt behaviours that may damage their health (Graham and Power 2004; Kawachi and Kennedy 1997; Wilkinson 1996).
As a result, there is a steep social class gradient for many different conditions that affect health (DH 2008a). For example, the death rate from coronary heart disease (CHD) is three times higher among unskilled workers than among professionals. Similarly, deaths from lung cancer are four times higher among unskilled male manual workers of working age than among professional men (reflecting the fact that smoking is much more common among male manual workers than their professional counterparts) (Twigg et al. 2004).
Government policy encourages PCTs, local authorities and others to identify and target groups and neighbourhoods where health – and the use of health services – is worst. For examples, see below.
'Health inequalities – progress and next steps' (DH 2008b) sets out how the government intends to invest in programmes that have proved a success to achieve its 2010 health inequalities targets. Beyond 2010, it plans to develop new goals, structures and systems to support delivery and sustain the improvements that have been achieved.
The latest comprehensive spending review (HM Government 2007) makes reducing health inequalities a priority, as does the operating framework for the NHS in 2008/09 (DH 2007a). It has also been made a priority in NHS planning guidance for the three years until 2011 (DH 2008c).
The document 'PSA delivery agreement 18: promote better health and wellbeing for all' reaffirms the government's commitment to reduce (by 2010) the social class gap in infant mortality and the life expectancy gap (including mortalities from CVD and cancer) between the most deprived areas and the rest of the population. (The most deprived areas are defined as the Spearhead group of local authority and PCT areas.) It also reaffirms its commitment to reduce smoking prevalence among 'routine' and manual groups (HM Government 2007).
The cancer reform strategy (DH 2007b) makes reducing the social class differential in the prevalence of cancer a priority. It highlights action to prevent cancer, particularly by reducing smoking among the population.
From 2008, new statutory requirements arising from the Local Government and Public Involvement in Health Act 2007 underpin local partnership working, particularly between local authorities and PCTs (UK Parliament 2007). For example, local authorities and PCTs must carry out a joint strategic needs assessment for their area and agree joint local area agreement (LAA) targets (Department for Communities and Local Government 2007). These new requirements are a feature of national performance management and should create a more supportive environment for the NHS. They support the NHS strategy to reduce mortality and morbidity from cancer, CVD and other smoking-related diseases and the white paper 'Pharmacy in England'. (The latter wants to see pharmacists' providing a range of smoking cessation services (DH 2008d).
Helping people to stop smoking and the provision of statins are two of the most widely used interventions to prevent cancer and CVD. Both have been shown to be effective and cost effective generally – and both have considerable potential to reduce premature mortality rates among people who are disadvantaged (Raw et al. 2001; Ward et al. 2007). However, numerous factors prevent them from being fully effective including: lack of available, appropriate and accessible primary care services; the reluctance of many people within vulnerable or at-risk communities to use health services or to follow agreed treatment (DH 1999; Dixon 2000).
Finding effective ways of identifying at-risk or vulnerable groups, tailoring services to make them accessible and keeping people in the system ('client retention') are still key challenges. For example, simply improving services does not guarantee that they will be used by those most in need of them. Nor will it necessarily increase the number of people who follow treatments they have agreed to.