"Fair society, healthy lives"

In presenting his report on health inequalities in England, Sir Michael Marmot responded to the question “what’s the one thing you would recommend based on the review of health inequalities you have just completed?” with “work as hard at you can and as we can to create a fair society. Creating a fair society would improve health and reduce health inequalities”.

The context of the review was the commission on social determinants of health which was set up by the WHO that published its report “Closing the Gap in a Generation” in August 2008. The title was a statement that we do have the knowledge to do it; it was a statement that we have the means to do it; the question was, do we have the will to do it?

“Fair society, healthy lives” has been widely quoted as showing that health inequalities have not narrowed, if anything they have got wider over the last decade. That is true, but if we look at what’s happened to the worst off in the decade from 1997 to 2007, life expectancy improved by 2.9 years in only 10 years. That’s about 7 hours every 24 hours. The issue is improvements were even better for the average and well off, so the gap between rich and poor didn’t narrow. Sir Michael argues that we need to focus on addressing the gradient or variation across social class and deprivation. The gradient suggests that we have to have universal solutions that run across the whole of society rather than the traditional targeted approach.

If everyone in society had the mortality rate of those with a University education, in other words we brought everyone up to the standard of the best off, we would prevent 202,000 people dying aged 30+, dying prematurely, which is 40% of the deaths and that translates, looking at the premature deaths avoided to 2.5 million life years. It would also bring 2.8 million extra years of life free from limiting illness of disability. Putting £ signs on those deaths or life years would be telephone numbers. The economic case us unarguable, we cannot afford to do nothing.

Sir Michael and his team took a life course approach and identified 6 policy areas that could make an enormous difference to improving health and reducing health inequalities. Every child the best start in life, education, a life long education, fair employment and good work for all, a healthy standard of living for all. Create and develop healthy and sustainable places and communities, strengthen the role and impact of ill-health prevention and 2 policy mechanisms, quality and health equity in all policies and effective evidence based delivery systems.

The report is packed full of interesting things, for instance, child development we know is influenced by children being read to every day at age 3. Reading to children every day positively affects cognitive development, it’s really a pretty simple intervention. Data from Canada shows that children read to daily reverses half of the disadvantages associated with low income in readiness to learn when children start school. A really simple intervention and if it wasn’t done by parents it could be done by others. There are lots of other examples and even a plug for the NHS Kidney Care funded Green Nephrology project that Andy Connor and others are driving forward.

But is it just another report? Several have drawn analogies with Douglas Black’s report at the beginning of the 1980s. The Black report was commissioned by a Labour Government and presented to a Conservative one. It was actually published in rather poor photocopy form over the August Bank Holiday weekend. It did have an enormous impact on our understanding and the research community and perhaps should be credited with helping to shape the thinking and trial design for Marmot and other research groups around the globe. In contrast “Fair Society, Healthy Lives” has broad cross party support from all the 3 main political parties. After the election there are likely to be differences in how the programme of work will be approached but this report clearly articulates what’s needed and how progress can be measured.

Short clinical guideline on phosphate management in people on dialysis

NICE have been invited to develop a short clinical guideline on phosphate management looking at the difference in practice between units and at the bone mineral chemistry achieved in the Renal Registry reports it is clearly an area of large variation and uncertainty. Hopefully the NICE guideline will make it clearer for patients, their families and the renal multiprofessional team. Further details will be posted on the NICE website shortly.

Lessons for everyone

“If there is one lesson to be learnt, I suggest that it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented”.

Robert Francis QC
Chairman of the Mid Staffordshire NHS Foundation Trust enquiry

The Francis report is a lesson in communication – well written and easy to read but remarkabley disturbing. The patient stories that make up volume 2 deserve to be read by anyone seeking to understand the impact of poor care on those who seek help in hospital and on their families.

“There were often only 2 nurses for as many as 24 patients, and on occasion there was only 1 nurse attempting to treat everyone on the ward”

“I cannot believe that my husband spent his last few days in such an uncaring and appalling environment”

“On one occasion she attended the hospital at about 6.00am to find her mother in a side room calling ‘please help me, please help me’”. The patient was covered in dried faeces and was completely naked. She ran down the ward to find the staff “chatting and laughing”. She assisted on washing her mother and it was “awful”. Her “hands were absolutely caked” and it “was dried and it was all up her arms and it was round her neck”.
The patient died later that night.”

“The least important people on these wards were the patients”.

The report found a culture where patients were reluctant to insist on receiving basic care for fear of upsetting the staff, the consultant body was largely disassociated from management, where there was lack of openness and target driver priorities.

“Safety is the responsibility of all staff, clinical and non clinical”. Lord Darzi defined safety and quality as the organising principles of the NHS. Robert Francis quotes 4 earlier reports on safety beginning with Sir Ian Kennedy’s enquiry into children’s deaths in Bristol. Francis states “it should have been obvious to any Trust management between 2006 and 2009, if not before, that a high priority was to be accorded to patient safety in all its aspects”. In mid Staffordshire the Board concentrated on financial balance and achieving Foundation Trust status rather than quality of care. There was a focus on process at the expense of outcomes, a failure to listen, lack of support for staff and a weak professional voice in management decisions. I would encourage everyone to read the executive summary and the chapters on safety, record keeping and communication. Francis makes 18 recommendations. They are all directed at the Board, the Trust Management, Secretary of State, Department of Health and Monitor apart from recommendation 13: all wards admitting elderly, acutely ill patients in significant numbers should have multidisciplinary meetings, with consultant medical input on a weekly basis and recommendation 18: all NHS Trusts and Foundation Trusts should review their standards, governance and performance in light of this report. Many of the insights and comments are relevant to kidney care and indeed all care. Our understanding of human behaviour can be improved by appreciating how people systematically go wrong. Two things shouting out from this enquiry for me are the importance of encouraging our public and patients to expect and demand quality as a right and the important leadership role that all clinicians have as the custodians of quality for individuals and groups of patients.

Improving donor identification and consent rates for cadaveric organ donation

A short clinical guideline is to be produced by NICE on this topic. Given the wide variation in deceased donor rates between critical care and neurosurgical units I am hopeful that it will identify and promote good practice. Further details will be available on the NICE website in due course.