Health Inequalities - the postcode lottery

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Health is not just about healthcare. The link between poverty and ill-health is well established by international and national research. A World Health Organization Commission that reported in 2008 on the social determinants of health found that health is influenced by factors like poverty, food security, social exclusion and discrimination, poor housing, unhealthy early childhood conditions, poor educational status, and low occupational status.

A report from the OECD last year again underlines that large inequalities in life expectancy exist by socio-economic status including education level, income or occupational group. On average across OECD countries, people without high-school diploma can expect to live about 6 years less than those with third-level education. People with low incomes are less likely to see a doctor because access to preventative services is concentrated among the better off.

These findings echo the findings of our own European Research Series Report that found that while the quality of health care is high in most EU countries, there are significant variations between countries with regard both to quality and access.  Perceptions of unmet need for health care and perceptions of poorer quality of healthcare continue to be greater amongst poorer people in Europe than richer

In Ireland, studies from the Irish Public Health Alliance (IPHA) detail striking differences in life expectancy and premature death between people in different socio-economic groups, and another OECD report from last year suggests differences in how Irish people report being in good health, depending on their income groups. Only 73 per cent of people in the lowest income quintile (lowest 20 per cent) assess their health as good, compared to 93 per cent in the highest income group (in 2017).

A range of studies provide evidence that is of great concern relative to inequality and health in Ireland. The 2018 Healthy Ireland survey highlights how those in more deprived areas:

• are less likely to rate their health as good or very good,
• are  more likely to have a long-term health problem; and
• are more likely to smoke and binge drink

The Healthy Ireland Survey for last year, 2019, found that people living in deprived areas are more likely to report that they had suffered from a wide range of conditions (25 conditions were asked about) within the past 12 months compared to those in wealthier areas.

Health Inqualities and Age

And that first OECD report referenced above found that Ireland was one of five OECD countries where people aged 65 and over in the lowest 20 per cent of the income bracket are more than twice as likely to report living in poor or fair health, compared with adults in the top 20% of income.

At the other end of the lifespan, the Growing Up in Ireland study highlights a widening health and social gap by the time children are just 5 years old. Children from the highest social class (professional/managerial) are more likely than those from the lowest socio-economic group to be considered very healthy and have no problems.  Another study from the Growing Up in Ireland series shows that economic vulnerability, particularly persistent economic vulnerability, has negative consequences for the socio-emotional development of children. So that reinforces the need for a policy focus on child poverty and deprivation to address child health.  Obviously, children’s wellbeing is still very much shaped by their parents circumstances and social position, which results in persistent inequalities despite improvements in health, education and other areas in Ireland over time.

Health Inequalities and Life Expectancy

Life expectancy is another area where there are differences between socio-economic groups.

Overall, Ireland shows an increasing life expectancy since the 1990s.  Life expectancy in 2017 at birth stood at 84 years for women and 80.4 years for men (both above the EU average).

However, life expectancy differs based on socio-economic background. For example, life expectancy at birth of males living in the most deprived areas in the State was 79.4 years in 2016/2017 compared with 84.4 years for those living in the most affluent areas. The corresponding figures for females were 83.2 and 87.7 years, respectively. The differential between female and male life expectancy was greatest in the most deprived areas.

This shows how poverty directly affects life-expectancy and the incidence of ill-health; it also limits access to affordable healthcare and reduces the opportunity for those living in poverty to adopt healthy lifestyles. Basically - poor people get sick more often and die younger than wealthier people, something that is actually acknowledged by our own Department of Health.

Health Inequalities and Access to Healthcare

One of the most obvious concerns about the Irish Healthcare system, and a key concern, is to do with access.

Ireland’s health system ranked 22^nd out of 35 countries in the 2019 Health Consumer Powerhouse report, but on the issue of accessibility, Ireland ranked worst. That  report notes that even if a waiting-list target of 18 months were reached, it would still be the worst waiting time situation in Europe.

We know that Irish hospitals are working near full capacity. The occupancy rate for acute care, hospital, beds is among the highest in OECD countries – it’s 20 percentage points higher than the OECD average in fact, and while that can be a sign of hospital efficiency, it can also mean that too many patients are treated in hospitals when the would more appropriately be treated at home or within the community setting if that were available. Also, by comparison with other OECD countries, the share of the Irish population delaying or going without care is also comparatively high (above 30 per cent).

Our complex two-tier system for access to public hospital care means that private patients have faster access to both diagnostics and treatment, while those in the public system can spend lengthy periods waiting for a first appointment with a specialist and for treatment.  The statistics from the National Treatment Purchase Fund, for July 2020, show that there are more than 600,000 people are waiting for outpatient appointments, with more than one in five waiting for 18 months or more.

Problems with the Irish healthcare system are often evident through difficulties of access though we know that that’s not the whole story. There are barriers in access to primary care, delays in Accident & Emergency Department admissions, and waiting times for access to hospital care in the public system. International experts have noted that Ireland is the only EU health system that doesn’t offer universal coverage of primary care and that, despite increased investment during the previous decade, when the financial crisis of 2008 hit, Ireland still had poorly developed primary and community care services.

Accessing our complex system depends on whether you have a medical card, a GP visit card, private health insurance, private resources to spend on health services, where you live and what type of services you’re trying to access; it is also those who are poorest, sickest and those with disabilities who find it hardest to pay charges, to negotiate access, and who ultimately end up waiting longer for care.

Those who are poor and sick without medical cards fare worst in terms of coverage and access. In 2017, almost one in three households where at least one person had a medical examination or treatment in the last 12 months reported that the costs were a financial burden. For households with children, the corresponding rate was higher, at over 35%.

Health Inequalities and Covid-19

We know that many front-line workers – our healthcare workers, our shelf-stackers, our postmen, our binmen, much of the so-called “unskilled labour” is low paid. These are people who are at high risk of contracting COVID-19 every day. For those living in what’s called intergenerational households, where granny and grandad, mammy, daddy and the kids are all under the same roof, they’re bringing that risk home to people who, by virtue of their health, frailty or other vulnerability, are at an increased risk of contraction.

In terms of the numbers, the new COVID geohive site is very interesting. Just looking at the data, and as of the 22nd February 2021, the 14 day incidence rate was 240.4 per 100,000 people. But not all areas are created equally. If we take Dublin as an example, a county with a range of socio-economic profiles, we can see the impact of poverty, service provision and safe employment.

The national incidence rate, as stated above, was 240.4 per 100,000 people. This compares to

• 145.3 in Blackrock
• 136.5 in Glencullen-Sandyford
• 204.8 in Killiney Shankill
• 266.1 in Firhouse-Boharnabreena
• Across the imaginary boundary that separates the electoral area of Firhouse-Boharnabreena and Tallaght South, and we see that Tallaght South has an incidence rate of 555.5, more than twice that of its neighbour.
• North-inner City has a rate of 487.3 - more than twice the national rate
• And it’s 798 in Ballymun-Finglas - more than three times the national rate

These numbers are stark and clearly debunk the myth that COVID-19 was a great leveller.

Tackling Health Inequalities

The pandemic has created many issues, but also provides an opportunity for Government to finally grasp the nettle of healthcare inequality, to address our two-tier system and to invest in primary care and Community Health Networks.  Allowing people to age well at home and creating the environment within communities is proven to have a positive impact on all of the issues I spoke of earlier. It also frees up spaces in acute hospitals for those who need acute care, and can reduce our capacity rate below the 95% at which it currently stands. Government needs to properly fund Slaintecare, including the €500m investment in infrastructure that was committed to every year for the first 6 years. We need more GPs and community healthcare teams, we need a reduction to the prescription charges from €2 to €1.50 and we need to properly address the waiting lists for mental health supports.

We need to tackle healthcare as part of a suite of basic services forming part of a New Social Contract.