FLORENCE NIGHTINGALE FOUNDATION
Addressing health inequalities by improving access to care
© 2015 MA Healthcare Ltd
M
en in the most deprived areas of England can expect to live 9 years less their more affluent counterparts. For women the difference is just under 7 years (Office of National Statistics, 2014). Given this challenging context, we reflect on the contribution of nursing in addressing health inequalities by improving access to care. The broad remit of public health activity is promoting and protecting health and wellbeing, preventing ill-health and prolonging life (Faculty of Public Health, 2013). Historically, nursing has embraced its role in public health in the three areas of prevention of illness, protection and promotion of health. Public health is a complex endeavour, requiring action to promote wellbeing, as well as to prevent illness (Tod and Hirst, 2014). A social model of public health recognises wider structural determinants of health including socio-economic, environmental and political influences (Dahlgren and Whitehead, 2007). In the most deprived communities, these determinants create multiple disadvantages that work together to reduce people’s health status (Tod and Hirst, 2014). The complexity requires a partnership approach with sustained action required of policy, industry, education, health services, health professionals and lay people (Tod and Hirst, 2014). The social model of public health does not focus on individual behaviour, but emphasises that healthcare action should not just be ‘downstream’—intervene only in individual treatment of illness. Attention is equally, or even more urgently, required ‘upstream’—preventive health care that has an impact on population health and avoids the need for downstream treatment. Fundamental to this work is tackling the barriers some people have to accessing health and social care services. For people with multiple disadvantage, disproportionate effort is required to ensure access to services necessary for health gain (Tod and Hirst, 2014). For many people who experience health inequalities, poor health is worsened because they struggle to access the care required. The health impact becomes cyclical. Take, for example, an older person living on a basic pension in poor-quality rented housing, with multiple comorbidities, who is bereaved. The older person is at increased risk of mental ill health and social isolation. Over time he or she may be less able to maintain a healthy
British Journal of Nursing, 2015, Vol 24, No 3
living environment with concomitant health decline and without the resources and capability to protect their wellbeing. Who will notice his or her increasing vulnerability and inability to access help? Assistance needed will be diverse e.g. accessing pension credit, social connections, affordable social tariffs for heating, affordable shopping, as well as care, assessment and treatment for their health problems. Nurses are part of an expert and accomplished workforce distributed across society, working in an impressively diverse range of roles. It is arguable, therefore, that nurses are often in the unique position to identify someone who is struggling. The challenge for nurses in all settings is to identify such vulnerability upstream. The upstream preventative approach underpins the Framework for Personalised Care and Population Health for Nurses, Midwives, Health Visitors and Allied Health Professionals (Department of Health and Public Health England, 2014).This is not easy, especially in times of austerity. It requires working beyond giving advice and information, and acting to promote the health of populations who often slip though the net, through referral, care provision and partnership. Examples include school nurses tackling homophobic bullying, increasing access to hepatitis C care for intravenous drug users, and preventing excess winter deaths and illness (Tod and Hirst, 2014). A number of challenges exist to conducting such work and evidencing its impact. First, much recent attention has been given to safe staffing in nursing (Ball et al, 2014). The RN4Cast research showed that when staffing levels are insufficient, key aspects of care are missed (Ball et al, 2014). Work left undone will include upstream work, recognising vulnerability and referring on. Having conversations with people about sensitive aspects of care requires time and trust, which can be especially difficult to achieve when staff and resources are stretched. A related difficulty is having up-to-date knowledge on existing services. Years of restructuring and financial pressure mean the landscape of services available from health, social care and the voluntary sector is continually changing. It is nearly impossible for nurses to be fully aware of what is available. How many nurses in acute care settings know what community weight management and smoking cessation programmes are available for their patients, or how to refer patients? How does the nursing profession evaluate
and evidence its contribution to tackling health inequalities and increasing access to care? In terms of lessons for evaluation, we suggest revisiting the Leeds Declaration (Long, 1997). This made recommendations for public health evaluation that are helpful in evaluating nurseled interventions. Key messages were to: focus upstream, centre attention on research that helps understand lay knowledge and experience, take pluralistic and realistic approaches to research and evaluation, and embrace collaborations with other health and academic disciplines. Nurses have great potential to increase access to care to enhance health and tackle health inequalities. However, nurses face some major challenges that require them to be responsive to current pressures, while focusing upstream. Robust evaluation will help guide their efforts BJN and demonstrate effectiveness. Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P (2014) ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 23(2): 116–25. doi: 10.1136/bmjqs-2012-001767 Dahlgren G, Whitehead M (2007) European Strategies for Tackling Social Inequities in Health: Levelling up, Part 2. http://tinyurl. com/mxmf6x5 (accessed 23 January 2015) Department of Health, Public Health England (2014) Framework for Personalised Care and Population Health for Nurses, Midwives, Health Visitors and Allied Health Professionals. http://tinyurl.com/lkwoqfs (accessed 23 January 2015) Faculty of Public Health (2015) What is public health? http:// tinyurl.com/cmh9cnb (accessed 23 January 2015) Long AF (1997) The Leeds Declaration: three years on–a symbol or a catalyst for change? Critical Public Health 7(1–2): 73–81. Office of National Statistics (2014) Inequality in Healthy Life Expectancy at Birth by National Deciles of Area Deprivation: England, 2009-11. http://tinyurl.com/o43jefn (accessed 23 January 2015 Tod AM, Hirst J (eds) (2014) Health and inequality: Applying Public Health Research to Policy and Practice. Routledge, London
Angela Tod, Christine Norton, Lesley Baillie, Christi Deaton, Lesley Lowes, Debbie Carrick-Sen
Florence Nightingale Foundation Professors of Clinical Nursing Research
Elizabeth Robb
Chief Executive, Florence Nightingale Foundation
137
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
Addressing health inequalities by improving access to care
© 2015 MA Healthcare Ltd
M
en in the most deprived areas of England can expect to live 9 years less their more affluent counterparts. For women the difference is just under 7 years (Office of National Statistics, 2014). Given this challenging context, we reflect on the contribution of nursing in addressing health inequalities by improving access to care. The broad remit of public health activity is promoting and protecting health and wellbeing, preventing ill-health and prolonging life (Faculty of Public Health, 2013). Historically, nursing has embraced its role in public health in the three areas of prevention of illness, protection and promotion of health. Public health is a complex endeavour, requiring action to promote wellbeing, as well as to prevent illness (Tod and Hirst, 2014). A social model of public health recognises wider structural determinants of health including socio-economic, environmental and political influences (Dahlgren and Whitehead, 2007). In the most deprived communities, these determinants create multiple disadvantages that work together to reduce people’s health status (Tod and Hirst, 2014). The complexity requires a partnership approach with sustained action required of policy, industry, education, health services, health professionals and lay people (Tod and Hirst, 2014). The social model of public health does not focus on individual behaviour, but emphasises that healthcare action should not just be ‘downstream’—intervene only in individual treatment of illness. Attention is equally, or even more urgently, required ‘upstream’—preventive health care that has an impact on population health and avoids the need for downstream treatment. Fundamental to this work is tackling the barriers some people have to accessing health and social care services. For people with multiple disadvantage, disproportionate effort is required to ensure access to services necessary for health gain (Tod and Hirst, 2014). For many people who experience health inequalities, poor health is worsened because they struggle to access the care required. The health impact becomes cyclical. Take, for example, an older person living on a basic pension in poor-quality rented housing, with multiple comorbidities, who is bereaved. The older person is at increased risk of mental ill health and social isolation. Over time he or she may be less able to maintain a healthy
British Journal of Nursing, 2015, Vol 24, No 3
living environment with concomitant health decline and without the resources and capability to protect their wellbeing. Who will notice his or her increasing vulnerability and inability to access help? Assistance needed will be diverse e.g. accessing pension credit, social connections, affordable social tariffs for heating, affordable shopping, as well as care, assessment and treatment for their health problems. Nurses are part of an expert and accomplished workforce distributed across society, working in an impressively diverse range of roles. It is arguable, therefore, that nurses are often in the unique position to identify someone who is struggling. The challenge for nurses in all settings is to identify such vulnerability upstream. The upstream preventative approach underpins the Framework for Personalised Care and Population Health for Nurses, Midwives, Health Visitors and Allied Health Professionals (Department of Health and Public Health England, 2014).This is not easy, especially in times of austerity. It requires working beyond giving advice and information, and acting to promote the health of populations who often slip though the net, through referral, care provision and partnership. Examples include school nurses tackling homophobic bullying, increasing access to hepatitis C care for intravenous drug users, and preventing excess winter deaths and illness (Tod and Hirst, 2014). A number of challenges exist to conducting such work and evidencing its impact. First, much recent attention has been given to safe staffing in nursing (Ball et al, 2014). The RN4Cast research showed that when staffing levels are insufficient, key aspects of care are missed (Ball et al, 2014). Work left undone will include upstream work, recognising vulnerability and referring on. Having conversations with people about sensitive aspects of care requires time and trust, which can be especially difficult to achieve when staff and resources are stretched. A related difficulty is having up-to-date knowledge on existing services. Years of restructuring and financial pressure mean the landscape of services available from health, social care and the voluntary sector is continually changing. It is nearly impossible for nurses to be fully aware of what is available. How many nurses in acute care settings know what community weight management and smoking cessation programmes are available for their patients, or how to refer patients? How does the nursing profession evaluate
and evidence its contribution to tackling health inequalities and increasing access to care? In terms of lessons for evaluation, we suggest revisiting the Leeds Declaration (Long, 1997). This made recommendations for public health evaluation that are helpful in evaluating nurseled interventions. Key messages were to: focus upstream, centre attention on research that helps understand lay knowledge and experience, take pluralistic and realistic approaches to research and evaluation, and embrace collaborations with other health and academic disciplines. Nurses have great potential to increase access to care to enhance health and tackle health inequalities. However, nurses face some major challenges that require them to be responsive to current pressures, while focusing upstream. Robust evaluation will help guide their efforts BJN and demonstrate effectiveness. Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P (2014) ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 23(2): 116–25. doi: 10.1136/bmjqs-2012-001767 Dahlgren G, Whitehead M (2007) European Strategies for Tackling Social Inequities in Health: Levelling up, Part 2. http://tinyurl. com/mxmf6x5 (accessed 23 January 2015) Department of Health, Public Health England (2014) Framework for Personalised Care and Population Health for Nurses, Midwives, Health Visitors and Allied Health Professionals. http://tinyurl.com/lkwoqfs (accessed 23 January 2015) Faculty of Public Health (2015) What is public health? http:// tinyurl.com/cmh9cnb (accessed 23 January 2015) Long AF (1997) The Leeds Declaration: three years on–a symbol or a catalyst for change? Critical Public Health 7(1–2): 73–81. Office of National Statistics (2014) Inequality in Healthy Life Expectancy at Birth by National Deciles of Area Deprivation: England, 2009-11. http://tinyurl.com/o43jefn (accessed 23 January 2015 Tod AM, Hirst J (eds) (2014) Health and inequality: Applying Public Health Research to Policy and Practice. Routledge, London
Angela Tod, Christine Norton, Lesley Baillie, Christi Deaton, Lesley Lowes, Debbie Carrick-Sen
Florence Nightingale Foundation Professors of Clinical Nursing Research
Elizabeth Robb
Chief Executive, Florence Nightingale Foundation
137
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 11, 2015. For personal use only. No other uses without permission. . All rights reserved.
