“Poverty proofing” and a national strategy for the cost-of-living crisis

“Poverty proofing” services

The focus of the event was moving beyond “stating the problem” of social determinants of health to work out policy solutions that might alleviate the impact of health inequality. Some of these related to government policies, but the event also featured research into how doctors and NHS trusts themselves could “poverty proof” their services to increase their ability to reach the most deprived people in society, who have historically had less access to medical services.

One report, from Tees, Esk and Wear Valley NHS Foundation Trust’s youth mental health services, detailed an array of practical strategies that have helped the service reach the large number of families living in poverty in their region, which is often recorded as having the highest levels of poverty in the country.1 Working in conjunction with the charity Children North East over six months, the trust began to subsidise transport for those who could not afford to travel to appointments. It also streamlined the referral process to make accessing NHS services less taxing; offered more flexibility on appointments, including holding meetings with busy parents at their children’s school; and reduced the number of meetings needed for those who can’t afford to regularly take time off work.

“Every now and again, we have a family who can’t answer a call from us, because they don’t have credit on their phone or don’t have a phone. And they end up getting discharged because we send them a letter to say they need to call in, but they don’t have a phone or credit,” says Catherine Parker, a consultant in public health who works for the trust. “We had to start thinking carefully about whether we are creating an additional structural inequality by the way that we design our access to our services. And, in particular, things like email were actually much better than texts, because people can go into a town centre and access free wi-fi.”

She added: “It’s about us being really mindful of those costs for users and making sure that we’re not creating barriers, right down to when we’re asking someone, for example, to take a mood diary, not assuming that they’ve got access to a pen and paper in the household, which isn’t always the case.”

Explanation for excess mortality

Speaking at the conference, Gerry McCartney, professor of wellbeing economy at the University of Glasgow, warned that, although the covid-19 pandemic had a dire impact on the country, it was “nowhere near as large as the ongoing impact of health inequalities in the UK.”

He mentioned a 2020 paper from his team, published in the Journal of Epidemiology and Community Health,2 in which they found that, over the course of 10 years, the number of years lost due to social inequality was over six times higher than the government’s predictions for a worst case, unmitigated covid-19 pandemic.

McCartney, who is the former head of the Scottish Public Health Observatory, also mentioned a new paper, a preprint that has not yet been peer reviewed, in which he argues that the current cost-of-living crisis is having a devastating effect on excess mortality. “When we modelled this, we’re suggesting an up to 23% rise in excess mortality in an unmitigated cost-of-living crisis scenario for the most deprived [groups],” McCartney told the conference. “The mitigated scenarios brought that rate down, but it’s still set to be 8% in the most deprived groups. And that leaves a 6% predicted rise in mortality for the total population in a mitigated scenario, which is roughly what we’re seeing.” He added that, although medical officers had discussed a lot of possible reasons for the ongoing rise in excess mortality, “what’s absent from that debate at the moment is the role of economic factors.”

The conference began with an emotional speech by Michael Marmot, one of the pioneers for the idea of social determinants of health, who took aim at the devastating effects of austerity by the current government, a recurring theme of the event. He said that the government’s health policies had “been a disaster,” that years of budget cuts and rising inequality had caused a stagnation in life expectancy, and that ministers and MPs “don’t read the health literature” on the worrying effects of their policies because it’s not written by economists.

“Normal service has been resumed [since covid-19]. And now we’ve gone back to making poor people poorer. That’s the way we run our economy,” he said. “But that is changeable. That’s not a given.”