Health Inequality Impact Assessments: placing equity at the heart of healthcare

The WHO defines health inequalities as “differences in health status or in the distribution of health determinants between different population groups”. [1] Healthcare interventions have the potential to inadvertently increase health inequalities, [2] while NHS England has a legal duty [3] to reduce these inequalities. However, a 2018 government review found that there was “no evidence that inequalities in life expectancy have narrowed in recent years”, [4] highlighting that there remains significant disparities in both healthy life expectancy and life expectancy overall between the most and least deprived areas of the UK. [5]

Earlier this year, the Guardian published a series of pieces to mark the 10th anniversary of the Marmot review, linking discrimination to health inequalities, [6] and arguing that some of the factors which contribute to health inequalities are ultimately political. [7] The ongoing COVID-19 pandemic has further illuminated existing health inequalities, sparking public discussions about how certain populations such as ethnic minority groups are more greatly affected by COVID-19, [8] in part as a result of socio-economic factors. Meanwhile, members of our team have seen first-hand how the pandemic is bringing to light relationships between mental health and health inequalities [9], and issues of whose work is deemed valuable, whose rights are deemed worth protecting in areas such as access to reproductive healthcare. [10] Groups such as the Health Foundation are now questioning whether the light shed on inequalities by the pandemic might offer an opportunity to address them. [11]

Placing equity at the heart of healthcare will require evidence-based tools for policymakers and practitioners to use in ensuring that healthcare is compassionate, fair, accessible, and comprehensive. Health Inequalities Impact Assessments (HIAA) are one such type of tool, and they have the potential to be a powerful way of mitigating health inequalities during policy planning. However, there are different ways of examining health inequalities and inequities [12], and several different frameworks have been used in the development and implementation of these assessment tools. [13] Over the coming months, our research team aims to explore some of these tools, with the goal of determining how effective England’s current approach towards HIAAs are, and to explore what we might be able to learn from other health systems across the globe. As part of this process, we will conduct a systematic review of HIAAs, and will explore questions including:

1. What are the current approaches to HIAAs in the UK, and what challenges are being faced in maximising their implementation and effectiveness?

2. How are limitations to HIIAs being approached in other countries using them?

3. How are HIIAs tailored to the specific method of provision of healthcare present, and is this proving effective?

4. How could we apply approaches taken by other countries to adapt the UK’s current strategy regarding HIIAs and make their impact more widespread?

Based on the findings of this systematic review, we aim to formulate a policy paper to provide public guidance and recommendations on the future use of HIAAs in England, which we believe has the potential to provide powerful insight into how England’s policymakers can take the next steps in addressing health inequalities in our healthcare system.

Authors:

Kate McNeil holds a BAH (Distinction) in Political Studies and History from Queen’s University at Kingston and an MSc (Distinction) in Health and International Development from the London School of Economics. She is presently the Communications Coordinator for the University of Cambridge’s Centre for Science and Policy and UKRI’s Partnership for Conflict, Crime and Security Research. She is also a World Economic Forum Global Shaper and an alumnus of the European Forum Alpbach.

Victoria Ford is an MPhil student in Health, Medicine, and Society at the University of Cambridge. She holds a BA (Dean’s Honours List) in Gender, Sexuality, Feminist, and Social Justice Studies from McGill University. Her work and activism focus on gender health equity. She serves as the Chair for the Sexual and Reproductive Health Committee with Students for Global Health, is Vice-President of Cambridge Health Leaders, and is a member of the Robinson College Feminist Society. Victoria is a proud recipient of the Cambridge Vice-Chancellor’s Social Impact Award and the McGill Scarlet Key Award for her initiative: Medical Herstory which works to de-stigmatize women’s health.

Rhea Mittal is a third-year medical student at the University of Cambridge, currently undertaking an intercalated degree in Psychology, Neuroscience and Behaviour. She has a strong interest in global health policy. She is passionate about access and outreach, currently working as a mentor at Project Access and volunteering with Cambridge Hands-On Science (a science outreach organisation).

Rachel Ibbott is a second-year Natural Sciences undergraduate at the University of Cambridge. She has become interested in public health over the past year, and is also involved in Students for Global Health and UAEM. She is looking forward to developing her skills in research and writing for policy during the next few months, as well as applying her science-based learning in a wider context.

Jess Knight is a third-year medical student at the University of Cambridge, currently undertaking an intercalated degree in Biological Anthropology. She has contributed to research papers on molecular mechanisms in cardiovascular disease whilst working as a laboratory intern at the Yale School of Medicine but is looking to broaden her expertise into global health and social policy.

References [1] “10 Facts on Health Inequities and Their Causes.” World Health Organization. World Health Organization, April 21, 2017. https://www.who.int/features/factfiles/health_inequities/en/. [2] White, Martin, Jean Adams, and Peter Heywood. “How and Why Do Interventions That Increase Health Overall Widen Inequalities within Populations?” Social Inequality and Public Health, 2009, 64–81. http://www.mrc-epid.cam.ac.uk/wp-content/uploads/2016/10/WhiteM_etal_How_and_why_do_interventions_that_increase_health_overall_widen_inequalities_within_populations.pdf [3] “The NHS Long Term Plan: Equality and Health Inequalities Impact Assessment.” NHS. NHS, January 17, 2019. https://www.england.nhs.uk/publication/the-nhs-long-term-plan-equality-and-health-inequalities-impact-assessment/. [4] “Chapter 5: Inequalities in Health.” GOV.UK. Public Health England, September 11, 2018. https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-5-inequalities-in-health. [5] “Chapter 5: Inequalities in Health.” GOV.UK. Public Health England, September 11, 2018. https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-5-inequalities-in-health. [6] Butt, Jabeer. “Discrimination Link to Health Inequalities | Letter.” The Guardian: Letters. Guardian News and Media, February 27, 2020. https://www.theguardian.com/world/2020/feb/27/discrimination-link-to-health-inequalities. [7] Editorial. “The Guardian View on Inequality and Health: a Matter of Life and Death | Editorial.” The Guardian. Guardian News and Media, February 25, 2020. https://www.theguardian.com/commentisfree/2020/feb/25/the-guardian-view-on-inequality-and-health-a-matter-of-life-and-death. [8] Cookson, Clive, Hannah Kuchler, and Richard Milne. “Nations Look into Why Coronavirus Hits Ethnic Minorities so Hard: Free to Read.” Financial Times. Financial Times, April 29, 2020. https://www.ft.com/content/5fd6ab18-be4a-48de-b887-8478a391dd72. [9] “Health Matters: Reducing Health Inequalities in Mental Illness.” GOV.UK. Public Health England. Accessed May 17, 2020. https://www.gov.uk/government/publications/health-matters-reducing-health-inequalities-in-mental-illness/health-matters-reducing-health-inequalities-in-mental-illness. [10] Hillary Margolis, “England Leads Way in UK after U-Turn on COVID-19 Abortion Access,” Human Rights Watch, Accessed May 15, 2020, https://www.hrw.org/news/2020/03/31/england-leads-way-uk-after-u-turn-covid-19-abortion-access. [11] Jo Bibby, Grace Everest, and Isabel Abbs, “Will COVID-19 Be a Watershed Moment for Health Inequalities?,” The Health Foundation, May 7, 2020, https://www.health.org.uk/publications/long-reads/will-covid-19-be-a-watershed-moment-for-health-inequalities. [12] Mariana C. Arcaya, Alyssa L. Arcaya, and S. V. Subramanian, “Inequalities in Health: Definitions, Concepts, and Theories,” Global Health Action 8, no. 1 (2015): p. 27106, https://doi.org/10.3402/gha.v8.27106. [13] J.s. Mindell, A. Boltong, and I. Forde, “A Review of Health Impact Assessment Frameworks,” Public Health 122, no. 11 (2008): pp. 1177-1187, https://doi.org/https://discovery.ucl.ac.uk/id/eprint/5218/1/5218.pdf.