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  • Naoimh McMahon

How the problem of health inequalities is moulded to fit within local health systems

A number of research studies have sought to explain how people working within local health systems come to think about health inequalities, and the actions they take to address them. I've recently pulled together the findings of these studies in a qualitative synthesis [1] (now free to access from Social Theory & Health).


I've been trying to think of useful analogies to capture the insights from this work. Inspiration has come from The Great Pottery Throw Down (which I'm enjoying!) and how, like clay, it seems that the problem of health inequalities is moulded, reshaped, and transformed to fit with dominant perspectives and practices within health systems. In this post, I summarise these processes, after first describing how inequalities are most often framed in practice.


How health system actors frame health inequalities


The included studies showed how health system actors thought about and framed the problem of health inequalities in different ways. When categorised along a popular continuum [2], the general trend was that the majority focused primarily on inequalities in healthcare access and lifestyle behaviours; some were also concerned to mitigate the impacts of the social determinants of health; and a few were explicit about the need to challenge the politics and policies that drive and sustain wider social and economic inequality.


Regardless of these differences, health system actors were said to predominantly frame health inequalities in terms of specific individuals, groups, or geographic areas felt to represent the 'worst off', 'most marginalised', or 'most deprived'. While intuitive, the concern for authors was that this approach translated into a narrow focus on individuals and increasing individual access to health promoting resources (i.e. healthcare, healthy lifestyles, and the wider determinants of health), at the expense of highlighting and challenging how these resources come to be so unequally distributed.


Why the problem gets framed in this way


Framing health inequalities in this way was said to result from a combination of (i) how health system actors are trained to think about health and intervention, and (ii) important institutional practices and pressures that limit what actions can be implemented.


Individual worldviews and backgrounds

Most health system actors have come through some form of clinical training. Such training typically promotes a focus on individuals rather than the contexts and conditions in which they live. It is also underpinned by a framework of biomedical knowledge that privileges causal explanations for health that are direct (i.e. A causes B), observable, and easily measured. It is this way of thinking that invariably leads actors to hone in on more immediate and modifiable 'risk factors' for individual health.


Health system actors who explicitly considered the social and political roots of such 'risk factors' tended to have had more direct experience of inequality (either personally or professionally), or had greater exposure to non-medical disciplinary perspectives and ideas (e.g. social work, political science).


Institutional practices and pressures

A number of studies highlighted how the use of different forms of statistical data to monitor and visualise health inequalities leads to the common practice of assigning a label to population groups (e.g. ‘at risk’, ‘vulnerable’, 'deprived'). As a result, it is the characteristics of these groups and communities that are most scrutinised, rather than the social and economic processes that create and sustain risk, vulnerability, and deprivation.


The honing in on clinical and social 'risk factors' within specific population groups was also found to be reinforced through a range of governance arrangements within local health systems. Authors highlighted in particular the influence of health inequalities targets; short-term funding arrangements and commissioning frameworks; and a requirement to be able to predict, evidence, and quantify the immediate impacts of investment. Collectively, these practices served to further 'medicalise' the problem of health inequalities, to promote a focus on 'quick wins' and, ultimately, to bias efforts away from much needed longer-term investment and action on the wider determinants of health.


Authors highlighted how this approach was rarely, if ever, challenged by either politicians or the public. Indeed, the primary concern amongst these audiences with acute care and hospital treatment meant a lack of external pressure on health systems to reorient their efforts towards tackling the underlying drivers of health inequalities.


The challenge of translating health equity ambitions into action

Lastly, the studies included in my review raised specific concerns about how health equity ambitions are often framed within research. For many health system actors, ideas around working 'upstream' or tackling the root causes of health inequalities were overwhelming, with even system leaders suggesting that they appeared in discussions as simply 'too big to tackle'. For some there was a sense that health equity was an 'umbrella term', and while there was certainly a commitment to addressing the problem, it fell short of providing a clear route map to guide day-to-day action on the ground.


Conclusion


Local health systems are increasingly tasked to play a more central role in driving action to reduce health inequalities. Recent reforms especially are challenging them to work in new ways with public and private partners to tackle the social and economic drivers of health inequalities. This literature however demonstrates how powerful perspectives and practices shape how health inequalities get framed for action within health systems. As such, it provides important insights for understanding the success or failure of contemporary cross-sectoral efforts to tackle the underlying drivers of health inequalities.


This blog post is based upon independent research funded by the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC). I’m currently funded by a NIHR School for Public Health Research Postdoctoral Launching Fellowship. The views expressed are mine alone and are not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.


[1] McMahon, NE. (2022). What shapes local health system actors’ thinking and action on social inequalities in health? A meta-ethnography. Soc Theory Health. 10.1057/s41285-022-00176-6

[2] Raphael D. (2011). A discourse analysis of the social determinants of health. Crit Public Health. 21(2): 221-236. 10.1080/09581596.2010.485606


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