Tackling health inequalities
Delivering accessible pharmaceutical care for everyone
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RPS Position Paper
Pharmacy teams in all settings play crucial roles in supporting people to get the most from their medicines and keep well. By providing accessible health care, pharmacy teams help tackle health inequalities. This position statement focuses on how pharmacy can go even further to reach currently underserved populations and deliver accessible pharmaceutical care for everyone.
The stark reality of health inequalities in Britain today were laid out by Professor Sir Michael Marmot, Director of the Institute for Health Equity, at the RPS annual conference in November 2022. Palpable shock waves rippled through the room as he shared chart after chart demonstrating the worsening picture of health inequalities since 2010 (see figures 1-4).
Pharmacy teams across all settings – community, hospital, primary care and specialist settings – already provide many services that can help reduce health inequalities. These services support people to get the best from their medicines, to improve their health and to live well. They cover a wide range of health improvements including in long-term conditions, substance misuse, sexual health and infections.
Community pharmacies provide accessible health services, including being located in areas of higher deprivation, which can put them at the front line of improving inequalities. This makes community pharmacies one of the few health services that has the potential to buck the inverse care law (which states that people who need health care the most are the least likely to receive it).
However, the bottom line is that pharmacy services, whether in primary care, community, hospital or specialist settings, do not reach everyone. Sadly, it is often the people suffering the greatest inequalities who do not access the full range of services that are available. This not only fails to address health inequalities, but worse, it can exacerbate them.
Jenny, a patient in Glasgow, told RPS of the barriers she had experienced: “The pharmacist saw me as nothing more than my script,” she said. Making assumptions about people drives them away, she explained. It is highly unlikely that this was the intention of the pharmacist, but what Jenny felt should make us all stop and think.
This position paper is born from conversations like this. We consulted with pharmacists, public health specialists, patients, other professions and pharmacy organisations. We scoped opinions through focus groups and surveys, and we attended meetings with experts in the field.
We recommend that to enhance our role in tackling health inequalities, pharmacy needs to think not just about what services it provides but also about how it provides them. This paper focuses on exactly that: how pharmacy can provide services in ways that reach currently underserved populations and deliver accessibility for everyone.
Fig 1: Impact of deprivation on mortality (from RPS conference)
Fig 2: Impact of deprivation on life expectancy (from RPS conference)
Defining Health Inequalities
Health inequalities are defined as avoidable and unjust differences in health and wellbeing between different groups of people. Health inequalities are determined by circumstances beyond an individual’s control which result in differences in:
- Health status
- Life expectancy
- Access to care (availability, opening hours, transport, information, language, experience, misinformation, fear)
- Quality of care
Factors that can lead to people suffering from health inequalities include:
- Socio-economic (deprivation, power, education, language, employment)
- Geography (region, urban/rural, neighbourhood)
- Protected characteristics (ethnicity, sex, age, disability, sexual orientation, gender reassignment, religion, pregnancy, being married or in a civil partnership)
- Determinants of health (poverty, housing, education, community)
- Groups vulnerable to being excluded (homeless, traveller communities, sex workers, drug dependence, modern slavery)
- Lack of diverse representation and cultural awareness in decision making and policy setting
- Active avoidance of engaging with health services (low self-worth, tolerating health conditions)
Many people facing health inequalities may experience more than one of these factors which can make them even more vulnerable to their effect.
Data indicate that health inequalities were reducing prior to 2010 but that this pattern has been reversed. The gaps are particularly striking in relation to deprivation and poverty. This was the finding of two key reports:
“Since 2010 life expectancy in England has stalled: this has not happened since at least 1900… The health of the population is not just a matter of how well the health service is funded and functions, important as that is. Health is closely linked to the conditions in which people are born, grow, live, work and age, and inequities in power, money and resources – the social determinants of health.”
– Health Equity in England: The Marmot Review 10 years on (February 2020) www.health.org.uk/publications/reports/the-marmot-review-10-years-on
“Between 2000 and 2012 [in Scotland], life expectancy was increasing, and avoidable mortality was decreasing. Progress was being made in deaths from cancer and cardiovascular disease, alcohol deaths and suicides. In line with these improvements, absolute inequalities in mortality outcomes were generally reducing. However, in the decade since we have seen a stagnation in these previous improvements and in some cases a worsening of outcomes and inequalities.”
– Health Inequalities in Scotland (University of Glasgow and the Health Foundation, October 2022) www.health.org.uk/sites/default/files/2022-11/health-inequalities-scotland-reportandappendices.pdf
Some key themes that have been proposed to help tackle health inequalities, which come both from our scoping work for this paper and from published resources, include:
- Create healthy communities
- Focus on prevention of ill health and improving good health
- Tackle discrimination
- Understand the huge impact of socio-economic deprivation
- Take a human rights approach*
- Ensure services are person-centred
- Be culturally aware in the provision of health services
- Pursue environmental sustainability alongside health equity [this is being covered separately in RPS sustainability policies]
- Improve communication between services so that people do not receive disjointed care or fall through service gaps
*A human-rights approach means being person-centred, treating people as individuals with respect and dignity, ending discrimination, empowering people, enabling shared decision making, and respecting and protecting human rights.
Fig 3: Impact of deprivation on obesity in children (from RPS conference)
Fig 4: Impact of deprivation on life expectancy (from Marmot Review)
Actions for Pharmacy
Every pharmacy team in every sector of pharmacy already supports people to live healthy lives and to get the best from their medicines. The actions set out in the sections below can be taken by all pharmacy teams in all settings to enable pharmacy services to reach more people, particularly underserved populations who are at most risk of health inequalities.
1. Deepen our understanding
The first step for pharmacy teams is to understand the health inequalities that people using the pharmacy service may face (whether that’s a community, hospital, primary care or specialist service). These fall into two categories: external factors relating to individuals’ life circumstances and internal factors relating to the pharmacy service itself.
1a: Understand our population
Demographic data for the population a pharmacy service serves can provide vital insights into meeting the population’s needs. Population health profiles could include age, life expectancy, socio-economic deprivation, employment, ethnicity, disability, avoidable mortality, disease prevalence for leading causes and faith. Public health teams in NHS organisations may have useful reports available or be able to advise on where to access local information. It may also be possible to access data via freedom of information requests to public bodies.
However, statistics only tell part of the story. Understanding your population also involves engaging with people directly. This might be through approaching local community or faith groups, seeking views from patients or gaining insight from pharmacy staff members. The richness of understanding you gain from hearing from someone living in poverty every day is significantly greater than reading about socio-economic data; similarly, speaking with someone of a different faith can transform your understanding of cultural differences.
Once you have gathered the information, consider who uses your pharmacy service:
- Does it replicate the population profile of your locality or are there groups missing?
- Are your services reaching the whole of your local population?
- What services are available in your locality?
- How can you reach people who are not currently accessing health services, for example those from excluded and underserved communities such as the homeless population, travelling communities or refugees?
These questions may need to be answered across a number of pharmacy teams in community, hospital, primary care and specialist services, with some teams providing services for specific populations. However, this only works if there are effective referral mechanisms in place and services are still accessible for patients. Pharmacy teams should also consider working with others, such as community and third sector organisations, to identify the underserved and “missing” populations and then work to close these gaps.