Various recent events have heightened awareness of potential discrimination as the cause of unfair and unequal treatment within the UK. These include the Windrush scandal, persistent health inequalities including different COVID-19 mortality rates, and assertions made in the Duke of Sussex’s autobiography. Discrimination (actions which are unequal between different groups), prejudice (attitudes and beliefs subordinating a group), stigma (negative behaviour in a social context) and bias (systemic subordination of a group within society and its associated institutions, including the legal system) describe the manifestation of an unequal relationship between groups of people, where one group is subordinate to a dominant group. There are many typologies often reflecting their different underlying theories, but regardless the concepts, are hugely important because they have the potential to explain the health outcomes of different population groups, which are evident across the NHS and its services.
‘health inequalities arise from experiences of racism and racial discrimination, which impact upon health status by causing physical and mental stress, with an indirect impact on socioeconomic status. ’
Despite opposition from both parties and the British Medical Association, the National Health Service Act 1946 was passed to launch universal healthcare in the UK in 1948, alongside the then Labour Party’s offering of a safety net of a minimum standard of living funded by a national insurance contribution made by employees. However, William Beveridge had assumed that it was possible to attain and sustain full employment and that health status would improve through access to universal healthcare. It was recognised that social and economic environmental factors impacted upon health and well-being and hence, the introduction of a safety net. Socioeconomic and environmental factors continue to influence health outcomes as evidenced by a comparison of the most affluent and most deprived life expectancy data, experience of poor health and severe mental illness (NHS England, 2019). Indeed, health inequalities between different group of people have persisted despite being avoidable and unfair.
Health outcomes are the product of complex interactions between many factors, including access to healthcare, health behaviours, education, employment, income and housing (The King’s Fund, 2022). The latest Office for National Statistics (2022) analysis of life expectancies and disability-free life expectancies in England and Wales confirms the relationship between the extent of deprivation and a longer and healthier life. The impact of the COVID-19 pandemic has reflected existing health inequalities with higher mortality rates among those living in deprived communities, those from ethnic minority groups and those with disabilities (The King’s Fund, 2022). The Health Foundation (2022) have argued that health inequalities are growing, drawing upon their analysis of patient data using the Cambridge Multimorbidity Score, which attempts to measure disease burden.
The Centre for Ageing Better (2021a) have asserted that from 30 years of age, the health status of different ethnic groups diverge so that the differences in the health status of older people from ethnic minorities and those of White populations are pronounced and that these differences have persisted for over 20 years (Stopforth et al, 2021). Stopforth et al (2021) analysed six large datasets covering England, UK or Wales, which over-sampled ethnic minority respondents spanning 1993-2017 to explore two health outcomes, namely, self-rated health and long-term illness that limited function. White/White British, Irish and Chinese respondents were highly represented in the most advantaged socio-economic positions, while Pakistani and Bangladeshi respondents were consistently highly underrepresented. Black Caribbean respondents were more frequently socio-economically disadvantaged in the earlier survey years, while Black African and Indian respondents were underrepresented in the highest quintiles across all survey years. Experiences of racial discrimination showed no clear pattern and experiences of abuse (verbal or physical) were less common than fearing racial harassment and taking avoidance actions (e.g. avoiding places). The logistic regression analysis revealed persistent health inequalities regarding long-term illness over time, particularly for Pakistani and Bangladeshi respondents and there were significantly higher odds of fair or poor self-rated health for Black Caribbean, Indian, Pakistani, and Bangladeshi respondents. There was a trend for a negative association between the experience of racial discrimination and health of varying strengths across the datasets, which suggests that health inequalities arise from experiences of racism and racial discrimination, which impact upon health status by causing physical and mental stress, with an indirect impact on socioeconomic status.
An analysis of data relating to those who are currently in their 50s and 60s (last baby boomers) suggests that their situation is considerably less favourable than in 2002 (Centre for Ageing Better, 2021b). Indeed, the number of people in their 50s and 60s in relative poverty had been rising between 2010/11-2019/20 notwithstanding demographic changes and population growth. The data analysis also suggested about 20% of the 50-70 years old cohort were likely to face long-term problems including poor health, financial insecurity and lack of social connections in old age with people from Black, Asian and minority ethnic (BAME) groups being at particular risk.
The most recent State of Ageing report (Centre for Ageing Better, 2022) highlights how growing older in the UK is an increasing challenge with financial security and a healthy later life becoming increasingly unlikely, as evidenced by a reduction in employment rates prior to retirement, changes in home ownership versus home rental rates, more people living alone without traditional family support structures, and a reduction in life expectancy and disability-free life expectancy. One in five homes headed by a person aged 60 years or over requires improvement and the current cost of living crisis and consequent pensioner poverty will exacerbate the health challenge of keeping homes sufficiently heated to avoid hypothermia and/or health deterioration.
Coastal towns and rural areas often have large populations of older people, not only because younger people emigrate for employment opportunities but also because older people immigrate for lifestyle reasons on retirement. North Norfolk is the local authority with the oldest average age (53.8 years) in England but other local authorities in Cumbria, Essex and Yorkshire also have notably older demographics (University of Central Tancashire (UCTan), 2022). While the evidence relating to mortality rates is contradictory, some good quality studies have reported more mental health problems, which may reflect the increased rates of social isolation and poor accessibility to community-based resources alongside financial challenges that impact upon transport, fuel poverty and housing issues (Public Health England (PHE), 2019a). Healthcare accessibility may be a particular issue including limited pharmacies, primary and community care provision and acute hospital services. Healthcare staff recruitment can be especially challenging (PHE, 2019; UCTan, 2022), which further undermines the quantity and quality of the provision with the anticipated transition to more digital health potentially increasing feelings of exclusion for those with limited digital skills and health literacy. UCTan’s (2022) analysis of data relating rural and remote communities highlighted how deprivation and health inequalities exist in rural and remote areas with NHS services affected by more workforce issues than urban NHS services; this has impacted upon post-COVID-19 service recovery. The higher prevalence of ‘diseases of despair’ (alcohol-related harm, addictions, self-harm, suicide) is noteworthy and the geographical and psychological isolation of these populations is matched with poor IT connectivity, which exacerbates the feelings of isolation while at the same time, impeding the roll-out of digital health services.
PHE (2022) has launched a resource as part of All our Health (PHE, 2019b) to enable healthcare professionals to include illness prevention and well-being promotion within their practice so that every healthcare contact counts. The challenge for community nurses and other healthcare professionals is to make a meaningful impact in the existing health inequalities and health disparities through recognising health need both in their clients and wider family groups and offering appropriate interventions. Proactive preventative interventions and the promotion of well-being is ‘everybody’s business’ within the NHS community.