Poverty and Health Inequalities – What Can We Do?

Last week the Chief Medical Officer, Professor Chris Whitty, came up to Lancashire. He spent the morning in Blackpool and then came over to see us in Morecambe Bay for the afternoon. It was an absolute pleasure to meet him and to welcome him here. He came to listen – the mark a genuinely kind and caring leader. More importantly he came to listen to people who live in these Northern Coastal Communities, to really hear what life is like and to allow that to impact his thinking and he prepares to develop further strategy on tackling poverty and health inequalities. As an epidemiologist, he is grounded in data and understands the issues at hand. What I really valued was his humanity and humility as he listened to the stories of people who live and work here.

 

Last year, the Home Secretary, Pritti Patel also visited Morecambe Bay. She came to Barrow-in-Furness and spent some time at The Well, a CIC which works with people in recovery from addiction and of which I am a Director. In an interview afterwards, she was asked about the impact of Austerity and the reality of poverty in communities like ours (4 in 10 children in Barrow grow up in poverty). Her answer was that poverty is not the (sole) responsibility of government. I put sole in brackets, because she tried to insinuate that the role of central government in tackling poverty that exists in local areas is very minimal compared to the responsibility of local government (who have had their funding massively cut by central government in the last 10 years), local schools, local public services and local businesses. I’ve really wrestled with what she said since that time because she’s not altogether wrong! But nor is she right! Of course Central Government has a huge role to play in tackling poverty. It’s undeniable that national policy, economic strategy, including taxation, land ownership and business development all have massive implications. But poverty doesn’t only exist because of Central Government. Health Inequalities do not just exist because of Central Government. I am not for one minute, negating or diminishing their role, but we do have to all ask ourselves why we see and tolerate such inequality and what we can all do to change this narrative. Because as Michael Marmot reminds us so powerfully in his book ‘The Health Gap’ – none of this is inevitable and it certainly doesn’t have to continue. Marmot holds that “if you want to understand why health is distributed the way it is, you have to understand society.” So if we want to understand society, then as Prof Bev Skeggs (Professor of Sociology at Lancaster University) so eloquently says: “Society is shaped by our values and what we value“.

 

If we are serious about ‘levelling up’, ‘resetting’ and tackling age old health inequalities then we have to understand that this is both complex, but also entirely possible and need not take 100 years! As Marmot says in his amazing book ‘The Health Gap’ – essential reading for anyone who cares about this issue – we must do something and we must do it now! Marmot’s research proves that health inequalities are not a footnote to the health problems we face, they are the major health problem. We can actually make significant and measurable differences in a short space of time – so why aren’t we doing more? In the rest of this blog I hope to look at how we can make a real difference to poverty and health inequalities in our communities. We all have a part to play, no matter who we are. This is absolutely an issue for central and local government, but it is also an issue for society as a whole in all its facets.

 

Prof Imogen Tyler has written a phenomenal book called ‘Stigma: The Machinery of Inequality’. It is, in my opinion, the most important book published this year (I know that sounds like an overstatement, but it isn’t!). I believe this must be our starting point when we talk about poverty and health inequality. If we don’t understand how we have all subconsciously and/or overtly accepted a narrative that ‘the poor are feckless and lazy and could just pull themselves up by their boot straps if they wanted to, because we all have the same opportunities,’ then we are blind to the reality of the stigma that surrounds poverty and how it is weaponised to maintain the status quo. The thing is – it’s not just the government who have used this narrative – it’s part of British culture. So many of our comedy programmes ridicule and scapegoat the poorest in our society – The Harry Enfield Show (‘The Slobs’), and Little Britain (Vicky Pollard) to name just two. think of how many reality TV shows, like ‘Benefits Street’ have reinforced the stereotypes. Our national press continue to bombard us with very particular perspectives on ‘benefits scroungers‘ and ‘migrant swarms‘ and we read it, we drink it in, and whether we like it or not, it embeds itself as a way of thinking in our minds. That’s how propaganda works. It creates a corporate mindset by ‘othering’ our fellow human beings and pitting us against one another, rather than bringing us together to collaboratively find solutions in a way that works for everyone.  It takes significant and sustained effort to do our own internal work around stigma, racism, white privilege, sexism and toxic masculinity. But if we want to build a society shaped by our values and what we really value then whoever we are – this is where we must begin. Our first work is to demolish the strongholds in our minds, challenge our unconscious biases and undo our ‘go to’ narratives, replacing them with deeper and better truths about the innate value in every human life. We must be determined to create the kind of language which reflects this because language gives substance to our thoughts and beliefs. This important work needs to weave its way through every part of our education system. This will take effect in shifting the corporate mindset through the way we teach history in our schools, for example, with a more honest appraisal of the negative effects of colonialism, or indeed how the feudal system continues to dominate the price of land and the unaffordability of good quality housing. We need to equip the rising generation with the tools they will need to undo the damaging ideologies of stigma and find solutions to the issues they are facing around social justice and climate change.

 

Imogen draws on the work of The Poverty Truth Commission, here in Morecambe Bay and in other places to highlight ways in which we can break down stigma, build friendships and create a kinder society. The Poverty Truth Commission gives us a real insight not only into how we break down stigma, but how the building of friendships across the dividing walls in our society creates a new political space from which we can create ‘the good life’ together. Our political systems have become far too removed from every day life and we need a radical shift from disengagement to much wider participation in community life and decision making. There are so many voices calling for this from all sides of the political spectrum. We so badly need to break out of our entrenched twitter-siloed positions and learn to curate the space for a more collaborative and co-operative form of political and economic conversation and prioritisation. It is, in my view, impossible to think about breaking down health inequalities without involving those who experience them most severely to be a part of finding the solutions. For further reading on this: Radical Help by Hilary Cottam, Rekindling Democracy by Cormac Russell and Greed is Dead: Politics After Individualism by Paul Collier and John Kay are all vital texts. This requires a much more local, devolved, participatory kind of politics – the kind of thing made possible through initiatives like ‘The Art of Hosting’, ‘Citizens Jurys’ and ‘People’s Assemblies’ underpinned by principles of love and kindness. In this way we can create much more realistic ‘deals’ (like the one in Wigan) between public sector organisations and people in our communities. This might all sound a bit wishy washy, but as Marmot demonstrates, “the lower people are in the socio-economic hierarchy, the less control people have over their lives.’ He argues that “tackling disempowerment is crucial for improving health and improving health equity” This is where the circular arguments about absolute or relative poverty are missing the point. When Philip Hammond stated as Chancellor of the Exchequer that he ‘doesn’t see poverty in the UK‘ – he was talking about absolute poverty and implying it isn’t an issue in the UK. He’s profoundly wrong. Economist Amartya Sen helps us understand this: “Relative inequality with respect to income translates into absolute inequality in capabilities: your freedom to be and do. It is not only how much money you have that matters for your health, but what you can do with what you have; which in turn, will be influenced by where you are.” Marmot argues that this means people in this position cannot participate in society with dignity. It is this active participation in ones own life and the life of the community around you, coupled with a sense that you can be part of the change that needs to happen which underpins the strap line for the poverty truth commission. “Nothing about us, without us, is for us.” If we want to tackle poverty and health inequalities in our society we have to radically include those who are currently most marginalised to be part of the change with us. We’re not trying to fix them. Together, we are trying to untangle the injustice that allows this kind of staggering inequality to continue.

 

The NHS is currently exploring its own role in tackling poverty and health inequalities. As the biggest employer in the country it has the opportunity to make a massive difference as an Anchor Institution, setting a good example and creating a network, both locally and nationally for other partners to collaborate with. Along with other local employers it can make a vast difference through positive employment schemes for people from poorer communities, paying a living wage, procuring locally and developing apprenticeship schemes, to name just a few ideas. We have developed a charter in Lancashire and South Cumbria, which we hope will be nationally available soon. I’ve previously written on the role of Primary Care Networks (PCNs) and how taking a ‘radical help’ approach with our communities could make a real difference at a local level. PCNs have a particular role in Population Health Management. This approach that we are focusing on across Lancashire and South Cumbria uses the best in data science and enables health teams to focus in on the areas of greatest need, working with those communities to bring about change through co-creation. If the NHS is really serious about ‘levelling up’, however, one thing which must be explored is the national funding formula. If we’re serious about Population Health, we must be much more comfortable with allocating resources according to Indices of Multiple Deprivation. We must also change what we measure and ensure that Key Performance Indicators and clinical funding streams are much more aligned to this entire agenda. Incentives do change behaviour and we need to make sure that we’re getting them right, whilst permissioning PCNs, in particular, to have a change in focus. We need to make it more attractive to work in areas of higher complexity and create more sustainable models of care. It is my belief that without a Health Inequalities lead at the top table of NHS England and Improvement, the right level of accountability and prioritisation simply won’t be there. It won’t be enough just to have someone accountable in each system, vital though this is. Integrated Care Systems must take an evidence-based approach and recognise what a profound difference they can make in a short space of time. The drivers in the system must be wedded to this way of working. The NHS must stop spending such a colossal amount of money tinkering around the edges of helping people to live a bit longer and get deep into the game of tackling the vast and ongoing health inequalities in our society. It must use it’s powerful voice to continually challenge policies which make this worse and actively campaign to make society more equitable. Marmot and The King’s Fund have already detailed so much that the NHS can do. Olivia Butterworth and Sara Bordoley and their teams are doing some great things. We need more of it! It’s time to act!

 

The issue of land and the lack of affordable housing has a huge effect on people being locked in cycles of poverty and creates massive health inequalities. Central Government has a huge role in sorting this out, but increased devolution may make it become easier with increased public participation in the daily politics of life. Most of the way our land is distributed and inflated was designed in the 11th Century and through the Middle Ages. Alistair Parvin has written the most phenomenal piece on this issue and it deserves time to be read and digested. He makes a very tight case as to why we find ourselves in the situation we are in, but encouragingly he comes up with some really possible, pragmatic and solutions-focused ideas about how we can solve this, if we want to. Of course there are many vested interested and people in positions of significant power, who would resist such an approach, but we must not let that stop us having some grown-up conversations about this. Parvin accepts that it would take a government with extraordinary vision and bravery to do what is really needed and offers some really helpful pragmatic smaller steps that would get us in the right direction.

 

I am not going to copy and paste his paper here, but I hope this whet’s your appetite enough to seriously engage in the possibilities. We can’t keep passing this ball to future generations. We have a once in a lifetime opportunity to reset our economy and in this time of ‘jubilee‘ we need to grasp this nettle if we are serious about creating a society that truly works for everyone. Mariana Mazzucato, Kate Raworth, Katherine Trebeck and Carlota Perez are just some of the brilliant people creating the kind of economic and technological frameworks we need. It’s time to build an economy of hope, shaped by our values and focusing on what we value. We know that the UK population would like us to place health and wellbeing at the heart of the UK economy instead of GDP – this is a massive shift and one that we must hold onto. This priority along with the creation of more social co-operatives, new local/community banks and credit unions would all help us to create a fairer economy that really works for the people.

 

 

So, we all have a role to play. As individuals, in our communities, through our work and via a more engaged, participatory, devolved, democracy, we need to deal with stigma and ‘wicked issues’, be determined to be more  switched on, truly engaged and find together some pragmatic solutions fit for the 21st century.  Disengagement is not an option. Let us not miss this moment. We can and we must do something. As Michael Marmot says in the final sentence of ‘The Health Gap’: “Do something. Do it more. Do it better.”

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Our Nation’s Biggest Public Health Problem

The subject of this blog is sensitive and difficult. It may stir up some difficult issues or memories for you, as you read. If this happens, then please take time to seek the help you need. I believe this blog and ones to follow might be some of the most important I have written to date.

 

UnknownI am currently reading a phenomenal book, sent to me in the post, by a dear friend of mine, who is a trained counsellor and knowing the work I do, felt that I should read it also. The book is called “The Body Keeps the Score” by the eminent Psychiatrist, Bessel Van Der Kolk. In my humble opinion, it should be compulsory reading for every person training in any of the clinical specialities, including public health and for those working in education. The book focusses on the detailed research and work done by Van Der Kolk and others at Harvard over the last 30 years in the whole area of Complex Post Traumatic Stress Disorder (CPTSD), or “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS). It is not a part of our vocabulary, unfortunately, because even now, after a huge evidence base and many studies, there still remains no such psychiatric diagnosis. However, it is a hidden epidemic affecting huge numbers of our population and is the root of many of our major public health issues. So what causes this problem and just how wide spread is it? The evidence shows so strongly that the cause of CPTSD or DESNOS is Adverse Childhood Experiences, which we more starkly call Child Abuse.

 

Child abuse falls into four main categories: Physical abuse, Sexual Abuse, Verbal Abuse and Emotional abuse – usually in the form of neglect. 10% of children suffer regular verbal abuse. 25% suffer regular physical abuse. 28% of women and 16% of men have suffered sexual abuse. 16% regularly watch domestic violence. 87% of all those who suffer one type of abuse, are also abused in other ways. Each of these forms of abuseUnknown lead to major health problems later in life and studies are showing that it is not just mental health issues (many of which lead to inappropriate diagnoses like Borderline Personality Disorder or Bipolar Disorder and ineffective treatments) but also major physical health problems. Those who have been abused are twice as likely than others to develop cancer and four times as likely to have emphysema. The more difficult a person’s experiences, the higher the chance of developing heart, liver or lung disease at an early earlier age with much higher chances of taking more health risks with smoking, becoming overweight or having multiple sexual partners. There is good evidence to suggest a link with autoimmune diseases, such a lupus, and other complex conditions like chronic pain, chronic fatigue and fibromyalgia. The body cannot be separated from the mind and literally keeps the score of the internalised turmoil. So, even if the abuse happens before memories are formed, or our minds manage to forget or block out what has happened, the body simply cannot forget and sometime and in someway, the damage will show itself. Studies show that the overall cost of this appalling reality far exceed those of cancer or heart disease. In fact, eradicating child abuse would cut depression rates by over 50%, alcoholism by 66% and suicide, IV drug use and domestic violence by 75%. Antidepressants and antipsychotics are now some of our largest prescribing costs. We know this, but are doing very little about it. Perhaps it feels too big. Perhaps we don’t want to face the demons involved. Instead, we are numbing the problem, trying desperately to get people to be just functional enough to keep on serving the needs of our economic system, but we are not facing up to or dealing with this horrific problem, nor its true cost.

 

What can be done in the face of such evil? How can we develop aimages culture of compassion and restorative justice in which we can find a new way through for humanity? It isn’t getting any better. It is just as widespread and far reaching in its consequences as it was a generation ago. Is it possible for us to face up to the startling reality we face? Van der Kolk offers much hope, but it is not within the gift of the health service and social services to tackle this alone. If we are to take this issue seriously, we must embrace what Bessel refers to (at the end of chapter 2) as four fundamental truths:

 

  1. Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing.
  2. Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know and to find a common sense of meaning.
  3. We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through simple activities such as breathing, moving and touching – (learning to be present in our own bodies is a vital way of separating out the memories of the past which can overwhelm us at times).
  4. We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

images-1People can be healed of trauma. We need this at both an individual and corporate level. We have become so focussed on saving money, on quick fixes to ensure the NHS and Social Care System can survive, but we are ignoring the root cause of many of our ill health issues. If we are willing to face up to the truth of child abuse in our society and its long lasting and far reaching impact on overall health and wellbeing, then we might just be able to find a way through to healing and restoration of what has become an extremely broken society. In the blogs that follow, I will look at some of the ways we might find a way through this crisis of epidemic proportions. One thing we must face straight away is that we are spending our resources in the wrong places and are focussing our attention in the wrong areas. We must protect our children and help people learn how to be good parents. We must strengthen our school teachers and sense of community. We must invest in the first five years of life far more than we are doing so currently, especially those key first 12 months of bonding and attachment. Together, if we want to, with love, care, bravery and determination, we can change the future. There is hope. There is healing. Our systems are not yet designed to cope with this, but we must speak the unspeakable, break the silence and face up to the truth. The truth will set us free and enable us to develop the kind of wellbeing that every human being should be able to live within.

 

 

 

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