Health inequalities and the power of place

As health inequalities grow, localised solutions in the West Midlands are making a difference, as Kevin Gulliver reports

For four decades, the links between health, poverty and inequality have been securely established by a multitude of research studies. Perhaps the most celebrated of those advocating that health inequalities can be understood primarily as existing and persisting through ‘social determinants’ is Professor Michael Marmot.

It was Marmot who produced seminal reports for the World Health Organisation and the New Labour government linking economic and social conditions, and their distribution among the population, that most influence individual and group differences in health status.

Chief among them these social determinants are class and social status, relative wealth and poverty, neighbourhood characteristics, quality of environment, and housing. Determinants are arranged on a social gradient, running from top to bottom of the economy and society, with ‘high’ status individuals having better health than those of ‘low’ status. Differentials in life expectancy at birth of almost a decade have been evidenced between the fifth least deprived neighbourhoods in England and most deprived fifth.

A new report by the Human City Institute, ‘The Power of Place: Health Inequalities, Housing and Community in the West Midlands Conurbation’, which accompanied a recent lecture by Marmot in the West Midlands, shows that there is significant overlap between the social gradient, ‘place’ and tenure, since they are key markers of socio-economic and health status.

Health inequalities can be identified at all geographical levels. For example, major disparities in life expectancy exist between the countries and regions of the UK, between local authorities within regions, and most starkly, between neighbourhoods within local authorities. There are very strong correlations between life expectancy and income and employment deprivation at the neighbourhood level.

The most deprived neighbourhoods include larger concentrations of poor and overcrowded housing too, which poses major risks to health; including poor mental health, respiratory disease, long-term health and disability and the delayed physical and cognitive development of children. Cold housing is especially damaging for health and causes an estimated fifth of excess winter deaths. Insecure and short-term tenure housing is especially damaging for physical and mental health.

Since 2010, the West Midlands conurbation has seen a rapid increase in homelessness and housing need, precipitated by a lack of affordable housing and the loss of 3,500 social homes through the Right to Buy.

Statutory homelessness has increased by 94% in the last seven years to stand at over 6,500 households, compared with a 48% rise nationally and a 17% increase in the wider West Midlands. And rough sleeping rates have accelerated by 239% since 2010 – a greater rate than nationally and in most other regions outside London (although, at 132 people, still a relatively small number). Use of temporary accommodation (such as homeless hostels and bread and breakfast hotels) in the conurbation has risen by 183%, whereas for the West Midlands region recorded a 94% increase, and nationally it was 50%.

Levels of poor, hazardous and overcrowded housing are also on the rise. It is estimated that such housing costs the NHS £1.4bn annually. The prevalence of such housing is disproportionately located in the most deprived neighbourhoods across the West Midlands, as shown in the mapping study conducted for HCI’s report.

Despite drastic cuts in local government, social housing and community regeneration funding over the last decade, key agencies in the West Midlands, included in the HCI report as case studies, have developed a range of interventions in recent years to improve the health and wellbeing of deprived communities in the face of the consequences of austerity.

An initiative to tackle the causes of homelessness and rough sleeping, and to coordinate solutions with local stakeholders, was one of the first announcements made by Andy Street, the West Midlands Combined Authority mayor.

Social landlords are playing their part too. The Black County Housing Group has created a wide-ranging community investment strategy to improve the financial circumstances, health and wellbeing of residents, while generating a high social return on investment. Nehemiah UCHA, a BME housing association, offers residents at its elderly schemes the opportunity of a range of activities to improve wellbeing and reduce loneliness. And Holiday Kitchen, established by the Accord Housing Group, extends family wellbeing support and healthy communal meals for pre-school and primary-age children during school holidays.

Community-led approaches are also well-established. People’s Health Trust has created a ‘local conversation’ programme to confront health inequalities in Lozells ensuring that control is in the hands of local residents experiencing some of the highest levels of disadvantage in Birmingham to support improved pathways to health.

The research sector has equally played a part. Coventry University has created a Social Enterprise Unit to assist students in establishing social enterprises. And M-E-L Research has undertaken a series of major research projects to evaluate initiatives related to health, housing and disadvantage.

While the reduction of health inequities requires changes at national level to reduce socio-economic inequality, poverty and disadvantage, HCI’s report shows that localised solutions, especially those that actively involve communities, can generate telling improvements.