Prioritising public health: a qualitative study of decision making to reduce health inequalities

Abstract

BackgroundThe public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.MethodsWe conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.ResultsThe short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.ConclusionsIt is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.

A Secondary Analysis of the Childhood Obesity Prevention Literature through a Wider Determinants of Health Lens: Implications for Research Funders, Researchers, Policymakers and Practitioners

“…It is important to recognise that there are practical challenges that policymakers face when identifying approaches to implement. Policymakers are pressed to ensure that their proposed strategies are informed by good quality evidence, align with the political direction, are easily measurable / quanti able, able to demonstrate quick wins, and thus, are perceived to be an appropriate use of public money (35)(36)(37)(38). If the evidence base is focussed on downstream determinants, it is somewhat inevitable that this type of strategy will be implemented.…”

Invisibility of Social Vulnerability and Social Rights to a Comprehensive Health Care in Chile

“…The previous attitudes will allow nursing professionals to progress in the understanding, empathy, and sensitivity, going beyond a health control, as they promote interaction among caregivers and making visible the vulnerability and reasons to act with a conscious relevance. 2,11,[36][37] In order to increase the certainty of compliance with the public policy, integrating the concept that users in social disadvantage are subjects with unrestricted right to universal access to the services of the social protection system is necessary, especially at the primary level of health care. 29,31 CONCLUSION An elevated magnitude of invisibility of social vulnerability was found in mothers and children attended in the public primary healthcare system, showing the system inability to make itself visible.…”

“…10 The effectiveness of these policies depends, among others, on perception and detection of vulnerability by health professionals in the health care system, as well as integrated and synergic management capacity of public institutions in transferring the services to vulnerable people and groups. 5,[8][9]11 In the social protection policy, it was defined in the objective of process integration that institutions and their work teams are responsible for managing implementation, financing, and regulation of services. 5,12 This is a condition that has required ability for contextualized responses and new forms of institutional organization.…”

“…5,12 Collabo-ration between health services and local government institutions is considered to be the best way of obtain effectiveness and efficiency of health resources for poor people, as it has been based on collaboration between institutions and work integration between disciplines. [11][12] Previous reports showed disparities between professionals' perceptions about social vulnerability of pregnant women (8.6%) and data obtained from the Social Protection Records (91.4%). 13 At the same time, poor women are perceived by themselves as invisible, hopeless, and socially excluded, and such perception affects their possibilities of selfdetermination, autonomy, and enjoyment of the welfare rights.…”

Prospects for progress on health inequalities in England in the post-primary care trust era: professional views on challenges, risks and opportunities

“…Consequently it is not surprising that inequalities work is tacitly acknowledged to be less important than efficient service delivery, and staff are neither rewarded nor sanctioned for their performance on the health inequalities agenda [21]. Indeed, there is evidence of a substantial need for greater leadership and workforce capacity within the NHS to engage with the health inequalities agenda [24]. …”