In England justice is open to all – like the Ritz Hotel,’ goes the famous saying about how citizens can expect equal access to, but different outcomes from the law according to their means. These days a similar story can be told about our health system which has shown to be no remedy for unequal outcomes.
The Institute for Public Policy Research, a left-leaning think tank, recently announced that it was founding a cross-party Health and Prosperity Commission which aims to explore the links between poor heath, inequality and the UK’s current economic malaise. According to its preliminary research, people living in the most economically deprived parts of the UK, including Blackpool, Knowsley and Barking & Dagenham, can expect to fall into poor health in their late 50s, five years earlier than the national average and 12 years sooner than people living in the healthiest area in the country, Wokingham.
One of the Commission’s members Greater Manchester mayor Andy Burnham was quick to zero in on these regional disparities. ‘One of the fundamental beliefs of the British public is that everyone should have access to good health, irrespective of their means and location’ Burnham said.
‘But currently we see grave inequalities in health and opportunity across the country. Good health must be built into all the places people live across the whole country and communities must be supported to take greater control of their health and wellbeing. By doing this health can be the foundation of a just and equal economy.’
If you want a picture of regional health inequality, a good place to start is with respiratory disease. Recent analysis by leading lung charity Asthma + Lung UK found that people who lived in the most deprived 10% of areas were more than twice as likely to die from a lung condition than people who lived in the richest 10%.
The report also showed a North-South divide within England when it comes to poor lung health. Knowsley, Salford, Liverpool and Blackpool had some of the highest rates of emergency hospital admissions and deaths for lung conditions. While West Sussex, Kensington and Chelsea and Barnet had some of the lowest rates. Head of policy and external affairs at Asthma + Lung UK, Sarah MacFadyen explained that there were a wide range of contributory factors, with the major one being smoking. ‘Smoking is still the biggest preventable cause of lung disease. Although smoking rates are going down very quickly, we know that people are much more likely to smoke if they are from poorer backgrounds, working in manual jobs as opposed to professional ones.’
The North and the Midlands historically have had a large manual labour workforce, which has a high correlation with smoking habits. Jacqui Pollington, a respiratory nurse consultant working in Rotherham, describes how being situated near Sheffield, a traditional steel industry hub, means she has seen a lot of ex workers of the industry being treated in her clinic. ‘There is still very much that culture of smoking tobacco that leads these people to our doors, unfortunately,’ she says.
A common theme that Pollington had seen in the profile of her patients was their level of education. She said: ‘There is a link between academic attainment, smoking and employment, often all of those three in a respiratory clinic are markers in that there’s little academic attainment.’ The link between smoking and education is a key factor in widening inequalities. Pollington explained how those living in the least socioeconomically and academically deprived areas had adopted the wisdom that smoking was dangerous, in contrast to those living in the more deprived areas where the ability to assimilate that information and make changes was more difficult.
But it isn’t just smoking. For those working in traditional heavy industries, the working environment also presents its own hazards. For example, mesothelioma is directly linked to asbestos exposure which would have affected those who worked in shipyards or building in previous years. Speaking on her experience of treating ex steel workers Pollington says: ‘We see lots of patients who are working in these kinds of environments, although they’re very well protected and their respiratory protective equipment is a very high level working in that particular industry means constantly being surrounded by heat, fumes and particulates.’
Socioeconomic status may impact on where a person can work, but even more crucially where they can live. Those in socioeconomically deprived areas are more likely to live in cold or damp and mouldy housing. ‘And that’s because they’re often people who can’t make the same choices about where they live as people on higher incomes,’ explains MacFadyen.
The issue recently acquired more prominence when a coroner found that two-year-old Awaab Ishak from Rochdale had died from prolonged exposure to black mould in his parents’ housing association flat, which had been repeatedly reported to the management company but not acted upon. Michael Gove, the Government’s Levelling Up, Housing and Communities Secretary, described the death as ‘an unacceptable tragedy, and said the Government ‘should have been legislating earlier’ to tighten up regulation of social housing.
But even if the housing associations are compelled to clean up their act, there are hazards outside. Air pollution is a major driver of life-threatening respiratory conditions with Asthma + Lung UK reporting that it contributes to up to 43,000 premature deaths every year in the UK. MacFadyen expressed that London obviously has a big problem with air pollution, causing those living there to experience the harmful effects of air pollution.
Robin Hewings, a charity worker from Haringey told Asthma + Lung UK about how it has affected his daughter Nancy ‘There are days when the high levels of toxic air near Nancy’s school mean she can’t do sport or play with her friends. It’s hard to explain to a child that the reason she can’t play outside is something as intrinsic to life as the air you breathe.’
Being exposed to air pollution as a child can impact a person’s lung health as they get older. Pollington described how she sees patients in her clinic who have never smoked but have airflow obstruction. ‘When collecting a patient’s history the markers we look for are infant and childhood exposures from living in an environment where perhaps they were living close to a main road or a motorway structure.’ She notes that she is seeing patients with more severe air flow obstruction at a younger age. Which highlights how environmental factors can impact a person’s lung health.
In response to the analysis done by Asthma + Lung UK, the charity launched their ‘End the Lung Health lottery’ campaign urging the Government to ensure everyone gets an early diagnosis for their lung condition and receives support information after their diagnosis, as well as tackling the high rates of air pollution and smoking.
The Government recently revealed the world first ‘swap to stop’ scheme where smokers are encouraged to swap cigarettes for vapes in an attempt to cut smoking rates. While the scheme should go some way towards helping many to stop smoking tobacco, Pollington says that there are two key messages that the population needed to understand when it came to vaping. ‘If you are smoking tobacco switching to a vape is an extremely effective way of reducing the risk of exposure to tobacco smoke, thermal damage and the toxic damage. If you have never smoked tobacco your lungs just need clean air.’ She says that it needs to be made clear that no one is suggesting that vaping is good. But for people who have a nicotine addiction and have smoked their entire life, it can be a way to help manage the addiction.
And it should be part of a cohesive treatment plan for smokers to help them quit. ‘Many smoking cessation services have been taken out of healthcare and planted slightly separately for probably very valid reasons but it should be integral to long term condition management because tobacco addiction has such an impact on all of the other long term conditions,’ says Pollington.
Improving access to lung health assessments would also help narrow the inequalities in lung health. ‘If you think about targeted lung health checks they are all about nodule surveillance and early diagnosis of cancer and precancerous states but we don’t screen for lung health in any other way,’ says Pollington. Respiratory health testing is effort dependent meaning the person has to be able to understand that they must go and seek out help. However that may not be easy for people who have learning difficulties or have a language barrier.
Pollington says that in an ideal world she would like to see a non effort dependent lung function test be introduced. ‘COVID really introduced the concept of self monitoring and self managing but we don’t have anything like that where a person can check their own lung health at home.’ By improving access to the right diagnostic tests for people when they need can allow them to be given the correct medication quicker and therefore manage their symptoms to live healthier lives.
From a primary care perspective, Macfadyen says that everyone with asthma or COPD should be given an annual review to discuss symptoms and medication. Everyone who has an inhaler should be shown how to use it which does not always happen.
‘For COPD, we want to see everybody who’s eligible being referred to pulmonary rehab, which is a fantastic intervention, which has got really, really strong evidence behind it, that it can really help people manage their breathlessness and maintain the level that they’re at without deteriorating,’ she says.
However, Macfadyen highlights the shortage of pulmonary rehab available. Therefore, a lot can be done outside of hospitals to help people with their lung conditions however Macfadyen urged that the Government needs to step in with funding to make sure that the space, resources and the workforce are made available to meet the needs of the respiratory population.
Pollington displays models and posters in her clinic to help her patients understand better what’s going on with them if their literacy is poor. ‘Time and time again, the people coming through respiratory clinic doors in an area like this are predominantly manual working background as well as having other determinants of inequality and we give them leaflets with lots of text and technical things,’ she says.
The information that is sometimes provided to patients does not take into account the socioeconomic status of the person reading it. Having leaflets with a lot of jargon can make it difficult for people who have poor literacy to fully assimilate their condition. ‘I once had a patient in her 70s and we were talking about her lungs and she said to me, Do you mean I have two lungs? And it brought me up short to think again about who was in my clinical chair.’ Pollington says.
‘This patient had left school when she was 14 – nearly 50 years ago – and hadn’t been in a biology class or read anything health related and she had absolutely no idea what was going on in her own body.’ Having very basic and easy to understand health information about lung health could help those who potentially did not have the ability to gain a high level of literacy to have a better understanding of what is happening to them.
Perhaps the cusp of the problem is that respiratory reseach itself is a Cinderella service. According to Asthma + Lung UK only 2% of public research funding goes into respiratory diseases and yet they are the third biggest cause of UK deaths.
But either way Macfadyen argues that things will not get better without change. ‘I think what we may well see is that gap between rich and poor actually widening if we’re in a situation where fewer and fewer rich people are smoking or are able to live in areas with cleaner air, but poor people aren’t able to make those choices in the same way.’