Covering note for Council Members on the RCP Policy Statement
How Doctors Can Close the Gap:
Tackling the Social Determinants of Health through Culture Change, Advocacy and Education
The policy statement will be launched at a major conference at the RCP London on the 10th June 2010. The statement is a distillation of the outputs from three seminars which took place in the college between July 2009 and February 2010. At each of the meetings around 60 doctors and policymakers were brought together to discuss the avenues and opportunities for medical professionals to become more engaged in the social determinants of health and work to lessen health inequality in the UK. The project has been led by the President of the RCP and a steering group which comprises senior representatives from the Royal College of General Practitioners, Royal College of Psychiatrists, Faculty of Public Health, National Heart Forum and the Department of Health.
It has been frequently highlighted during the course of the project that there is a need for stronger advocacy from both doctors and students on issues of health equity. A transformation of healthcare systems with prevention, outreach and sustainability at their core and an increased focus on social issues in the education and training of all doctors also arose as prominent themes. The structure of the statement is based on these overriding premises and the recommendations have consequently been centred on changing attitudes, changing systems and changing education.
The majority of the attendees of the policy dialogues believed that doctorshave a crucial responsibilityin tackling the social determinants of health and can use their position as respected voices in their communities to influence, advocate, inform and build partnerships with other sectors (e.g. housing, education, employment, environmental), to promote health equality. Several of the recommendations aim to establish how doctors can both instigate and involve themselves in the development of schemes in socially deprived areas that create activity-friendly and green environments and have the co-benefits of both reducing carbon emissions and boosting a population’s physical and mental wellbeing. The statement also recognises the importance of transformingmedical education and training in order to give the next generation of doctors the skills, knowledge and motivation to effectively deal with issues around health inequity.
The recommendations contained within the statement are aimed at a broad range of delivery agencies, from individual doctors to the Department of Health and other public and third sector organisations, and this reflects the necessity for cross-sectoralprogrammes on the social determinants of health, working at both the macro and micro scale. The recommendations range from specific policy proposals – for example that ‘the training of all 2nd year foundation doctors should contain an element of primary care’ – to broader recommendations – such as ‘all doctors should consider the impact on health inequalities of their day-to-day practice’
RCP Policy Statement
How Doctors can Close the Gap:
Tackling the Social Determinants of Health through Culture Change, Advocacy and Education
For launch at the Social Determinants of Health conference on the 10th June 2010, subject to approval
Contents
- President’s Foreword
- Introduction
- Changing attitudes
- Changing systems
- Changing education
- Moving Forward
- Appendix
- President’s Foreword
The inequalities in healththat persist today in the UK are not inevitable. All sectors have a role to play in reducing the gap in health between the richest and the poorest in our society. Doctors are one of the linchpins in this endeavour and, within a permissive policy framework, must initiate, involve themselves in and advocate for programmes of action to tackle the social determinants of health and reduce health inequality.
This policy statement and the recommendations contained within it are a synthesis of the ideas and proposals to emerge from a series of policy dialogues organised by the Royal College of Physicians (RCP). Theaims of these dialogues were to identify what role doctors can play in reducing health inequality in the UK by acting on the social determinants of health, and how they can best be trained to do this.
Thestatement contains recommendations that cover the need for change in doctors’ attitudes towards the social determinants of health, a change in healthcare and social systems and a change in the education of doctors. The proposals are aimed at a broad range of delivery agencies, from individual doctors and their teams to the health departments of all UK administrations and other public and third sector organisations. This reflects the necessity for cross-sectoralprogrammes working at both the macro and micro scale.
There is an ever-increasing movement to confront social inequity and I believe this statementto be a timely contribution to this endeavour. It is set against the background of the recent report on health inequalities carried out by Sir Michael Marmot – Fair Society, Healthy Lives[1], and focuses more specifically on the roles of doctors, medical schools and the health service.
It is my hope that these proposals areread and acted on by doctors and policymakers of all levels and disciplines and that together we can strive to close the gap.
- Introduction
The social determinants of health can loosely be defined as how the circumstances in which people develop and live affect their mental and physical well-being and life expectancy, and have been characterised as the causes of the causes[2]of health. As well as age, sex and biological characteristics that are largely fixed, individuals are part of society and therefore the debates around health policy and healthcare provision must reflect the influence of societal, economic,environmental and cultural factors on a person’s lifestyle, as well as their interactions with familial, social and community networks. These interactions and layers of influence affecting health are represented in the well-known diagram devised by G. Dahlgren and M. Whitehead in the early 1990s [figure 1].
A healthy life is only in part dependent on health service provision and more restsonincome and the type and quality of education, housing, employment and food.It also rests on the physical and social infrastructure of communities –access to and uptake of healthcare and social support,the quality of services and amenitiesand environmental factors such as pollution and access to green spaces.There is much evidence that shows howsocial disadvantageand health inequity can result in vastgaps in health in the UK– in Calton, a deprived suburb of Glasgow, the average male life expectancy is 54 years, compared with 83 years in the affluent London Borough of Kensington and Chelsea[3].
Individuals and communitiesneed the support of the health system, health programmes, social services and local and national governments to create the enabling conditions for them to take effective health action. Doctors also need a permissive policy framework and the finances and capacity to adapt their practice in order to effectively tackle the social determinants of health. It is important to combine top-down policies with bottom-up actions.The distinct principles of equality (parity in health) and equity (fairness in health) must synthesise to promote good health for all.
In 2006/7 only 4% of the NHS budget was spent on prevention[4] and while this level had increased during the previous decade, it is still considered by many to be inadequate. Some doctors remain entirely focussed on the downstream medical interventions that they make, whereas all medical professionals need to adopt a population health perspective that looks beyond the immediate needs of individualpatientsand works to actively promote health and well-being. Doctors and other healthcare workershave a crucial stewardship role and can use their position as leaders within the health system and respected voices in their communities to influence, advocate, inform and build partnerships with other sectors (e.g. housing, education, employment, environment), to promote health equality.
Climate change is increasingly becoming recognised as a (social) determinant of health, and socially disadvantaged groups, who lack adequate environmental protection, resources and insurance, and are more prone to its effects on health[5] [figure 2]. Reflecting this, there is a growing movement in the health service towards the development of sustainable buildings and care pathways and also the promotion of programmes that have co-benefits for the environment and the physical and mental well-being of socially disadvantaged groups. A large number of primary care trusts (PCT) and strategic health authorities (SHA) have already signed up to the 10:10 campaign[6], that aims to reduce each member’s carbon emissions by 10% by the end of 2010 and this target could be adopted by healthcare services nationwide.
Between June 2009 and April 2010 the Royal College of Physicians ran a series of policy dialogues for doctors and policymakers to discuss the issues outlined above, and to establish the avenues and opportunities for medical professionals to become more engaged in the social determinants of health and work to lessen health inequality in the UK. Three of the dialogues were attended by senior delegates drawn from the healthcare and policy worldsand centred on avoidable chronic disease, climate change and the training of doctors.A fourth dialogue was organised for medical students. On each occasion a need for stronger advocacy from doctors and students on these issues, a transformation of healthcare systems with prevention, outreach and sustainability at their core and an increased focus on social issues in the education and training of all doctors arose as the prominent themes and these are reflected in the three sections that follow.
- Changing attitudes
In order for the medical profession to tackle effectively the social determinants of healtha holistic approach to the issuesis required,with doctors not only taking a lead in promoting and protecting health, and preventing ill-health,but also working collaborativelyacross the public sector to develop systems to reduce health inequalities.
It is recognised that there needs to be a higher degree of solidarity between professionals concerned with different facets of healthcare – all too often work is carried out in silos and information and ideasare not shared, resulting in a lack of collective purpose or vision. Less fragmentation of the major health institutions would enable them to act to address the social determinants of health in a far more effective and targeted manner.An increased interaction between public health teams and researchers, clinicians from primary, secondary and tertiary care and general practitioners, and a higher flow of data between these groups, will help to establish where health promotion activities are most effective.Information-sharing on the best practice in the UK (and beyond) concerning the social determinants of health should be encouraged and centralised.
Many doctors have long seen their role as the curers of illness and have paid insufficient attention to their responsibilities in health promotion. To deal with the social determinants of health,more effort and funding should be focussedearlierin people’slife-course to prevent disease and injury and health professionals must act to instigate and/or guide these initiatives. Doctors must also recognise that social deprivation can result in poorer health outcomes for people and candevelop programmes that outreach into socially disadvantaged and marginalised communities, and engage more in schemes that promote health literacyand to tackle ill-health, both before and after it becomes manifest.Doctors at all levels need to join forces to advocate for health equality – from impassioned medical students to influential deans and directors, the entire profession can use their powerful voices,whether on a personal, community or national level, to promote action on the social determinants of health.
All doctors should recognise and understand the effects of climate change on health and how healthcare systems will need to adapt in the face of shifting pressures,whilst reducing carbon emissions. Those with management responsibility in the health sector need to be informed as to the breakdown of the carbon footprintin their working environment, to allow them to easily identify areas for improvement. When allocating funds and resources it is pertinent to consider the triple bottom linemodel – the inclusion of social and environmental impacts to the traditional financial governance of an organisation. Doctors can also advocate directly to patients and encourage or refer them to take up activities that positively affect both their health and environment.
Recommendations
All doctors should consider the impact on health inequalities of their day-to-day practice.
Actors: All doctors
Senior medical figures and medical educators should legitimise, encourage and harness the power of student advocacy and action on the social determinants of health.
Actors: Deans, Course directors
Information-sharing on the best practice in the NHS concerning the social determinants of health should be encouraged and centralised.
Actors: Department of Health, Academy of Medical Royal Colleges (AoMRC)
Medical professionals should highlight and advocate for policy and programmes that have co-benefits both for the physical and mental health of socially disadvantaged groups and result in reductions in carbon emissions.
Actors: All doctors, NHS Sustainable Development Unit (NHS SDU)
All medical professionals should be educated and informed about the implications of their healthcare decisions on carbon emissions.
Actors: NHS SDU, SHAs, PCTs
Public health specialist teams should engage more closely with local clinical doctors in developing projects and programmes to promote and protect people's health, prevent ill-health and tackle health inequalities.
Actors: Faculty of Public Health (FPH)
- Changing systems
A major factor contributing to health inequality in the UK is the inability and/or reluctance of marginalised groups to present their symptoms to doctors or to access preventive services. This can result from physical or mental impediment, logistical issues,language barriers or even a stoic attitude towards health and a general acceptance of ill-health as inevitable.
All healthcare professionals need towork to better engage with their local communities and work to instigate and promote outreach projects to widen access to services andconnect with hard-to-reach sections of society.Outreach programmes should be designed to empower the public and take increased control of their health.It is vital to provide information and adviceon health issues, in a user-friendly, accessible way, to socially disadvantaged groups, and in particular younger members of these communities.Outreach programmes should go hand-in-hand with a broader restructuring of primary care services, where healthcare providers are more closely integrated with social services, education and childcare provision and employment services[7].The incentives systemin which general practitioners operate also needs to be examined with a view to promoting action on the social determinants of health.
During the consultation between a clinician and the patient there are opportunities to address the factors affecting their health beyond the formulaic approach of the social history. There are roles for clinicians at all levels and in all clinical settings, from general practitioners to those working in secondary care, to highlight the health risks of a patient’s behaviour and environmental circumstances[8].Clinicians can discuss with patients the impact of wider social determinants on their health, identifying areas that may have a significant health impact and signposting towards appropriate support and services, inside and outside the health sector. This could be through helping them to access health information, screening, health promotion and prevention services and treatment. Doctors can also help and encourage patients to act to modify their environment and actions. Transforming all consultations in this way could reap benefits both for the long-term care of the patient and prompt them to act as expert patients and advocate for health issues with their family, friends, colleagues and the wider communities in which they live.
Doctors can involve themselves in the development of schemes in socially deprived areas that create more efficient housing and activity-friendly and green environments: these have the co-benefits ofboth reducing carbon emissions and boosting a population’s physical and mental wellbeing[9].The sustainability of health services is becoming an increasingly prominent issue and new healthcare facilities need to be planned with sustainability and patient access as two of the most important factors in their design. Existing facilities can also be greened as much as finances and patient care will allow[10]. Health professionals and policymakers in this country could learn from resource-poor countries when designing new protocols and approaches, including increasing the amount of recycling and reusing of equipment and resources and reduction of waste. The reorganisation of healthcare and ill-health prevention services outlined above could also have the dual role of reducing patient miles and the overall carbon footprint of a service, as well as giving the opportunity to reach out to disadvantaged and marginalised groups in society.