CAIN: Democratic Dialogue: Social Exclusion, Social Inclusion (Report No. 2)

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Social Exclusion, Social Inclusion

Partners in health

Dr Paula Kilbane

Whatever index is used to define disadvantage, there has always been a considerable gap in health and wellbeing between the wealthy and the poor. Far from narrowing, the health gap in the UK has widened in the last decade.

This disadvantage starts at birth, with lower birth-weight babies and higher infant mortality rates in lower socio-economic groups. Death rates in young adults are higher, and there is a strong association between mortality rates for cancers, heart disease, chronic chest disease and liver disease and lower social class.

Northern Ireland has a younger population - with more children and fewer elderly people - than the UK as a whole. In the last decade, that population has grown at a faster rate than in Britain.

It also has a shorter life expectancy. While infant mortality rates in Northern Ireland have fallen to the UK average, the death rate for men is 8 per cent higher and for women is 4 per cent higher.

The major contributors are chest and heart disease-where, alongside Scotland, Northern Ireland leads the western world. The potential years of life lost to preventable diseases or conditions reflect the major impact of road traffic accidents and smoking.

Against this background of poorer health in Northern Ireland, there is a clear relationship between death rates and social deprivation. Amongst under-75s, differences in deprivation between areas account for 60 per cent of the variation in deaths.[1] Amongst the 30-65s, the deprived have a death rate twice that of the affluent.

Accidents, heart disease, stroke and lung cancer are the principal causes of death where the major differences occur. The deprived are three times as likely to die of lung cancer, whereas breast cancer and melanoma, a cancer of the skin, are more common in the more affluent. (Overall, life expectancy is diminished by 5.4 years for women and 6.6 years for men if they fall into the most, rather than the least, deprived category.)

Over time, moreover, the gap has been widening. Death rates have improved more in more affluent areas of Northern Ireland.

While measuring sickness is more difficult, long-term reported illness is more prevalent in the region than in England (though, again, it is similar to Scotland). As would be expected, rates are highest amongst the elderly, but there is once more an association with deprivation, which explains 10 per cent of the variation; long-term illness rates increase much earlier for those who are deprived.

Yet, together with Scotland, Northern Ireland enjoys higher per capita expenditure on health and social services than England and Wales. Some recent work suggests that the differential in Northern Ireland's favour is in the region of 6 per cent.[2]

This, however, conceals underfunding for investment, in capital and social services, and does not make any allowance for the high regional costs of some services (such as energy), as well as the need to be largely self-sufficient and the effects of the 'troubles'. And the gap between expenditure in Northern Ireland and that in England and Wales has been falling, due to the radical reduction in funding over the past five years. This has cumulatively reduced the budget in Northern Ireland by 11 per cent, whereas savings in England and Wales have been primarily effected through productivity gains.

Within the funding available to the region, over £1.3 billion, the vast bulk - 42 per cent-is spent on acute hospital services; a further 6.5 per cent goes to maternity and child health services. Average spending on health promotion services is just 2 per cent

This includes all screening, such as breast and cervical cytology, child and school health services, family planning and immunisation programmes. The proportion spent on direct health promotion is very small - perhaps £3-3.5 million for the region as a whole. That's 0.3 per cent of health spending.

Government policy is to move care from acute hospitals to the community, but resources have not measurably shifted, except in services for the mentally ill and those with learning disability or mental handicap. Developing medical technology, expensive drug therapy and consumer expectation have fuelled the demand for hospital services.

Staff, the public and their representatives are also understandably reluctant to forgo existing local and more accessible hospitals for what they consider the untested advantages of care in the community, based at local facilities and provided by teams of primary care workers from all disciplines.

Under these circumstances, it will be difficult to do more than contain the costs of acute hospital services. Reforms such as trusts and GP fundholding have been delayed in Northern Ireland and it is thus too early to measure their effects.

Improving public health is a complex task, requiring a focus on the most disadvantaged. For this to be successful, responsible statutory agencies must operate at both macro- and micro-levels.

At the macro-level, they must develop partnerships with other bodies which may control environmental and economic factors-and funding.

At a micro-level, efforts must concentrate on developing true partnerships with individuals and communities, which recognise both the reality of the circumstances in which they live and their views about health and the priority which they accord to it.

This means major change for professional working: it requires much more listening to people as individuals - more discussion about options, about choices and consequences. It means recognising that professionals do not have a monopoly on wisdom - while they may have a scientific basis in fact. And it means realising that effective health promotion is heavily dependent on understanding of, and respect for, local social and cultural factors.

There are examples of effective community development work in health. The Whiterock Liaison Health Committee in Belfast and the Lay and Health Information Workers Projects have been successful. Women's groups have taken the lead in the Shankill and Ballybeen in Belfast and in the Derry Well Woman Centre.

These initiatives are often underpinned by voluntary organisations, such as Save the Children and the Northern Ireland Voluntary Trust. The principle of success has been the empowerment of individuals and groups, to take action which they consider necessary on areas of health relevant to them, supported by professional workers. The many funds now available for disadvantaged areas need to be harnessed to support such initiatives. In its recently published draft strategy,[3] the Department of Health and Social Services formally endorsed a community development approach. This is most welcome.


1 Eastern Health and Social Services Board, Public Health Matters 1992-93: The Fifth Annual Report of the Director of Public Health, Belfast, nd
2 J Jamieson, 'Comparisons of HPSS Expenditure Patterns between Northern Ireland and Great Britain', in Choices: Proceedings of the Spring Seminar of the Northern Ireland Health Economics Group, summer 1995
3 Regional Strategy for Health and Social Wellbeing 1997-2002, DHSS, Belfast, 1995

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