Mental Health Inequalities among the Mentally Ill Older Population in the UK - Essay Example

Contribution of public health in addressing mental health inequalities among the mentally ill older population in the UK Introduction In the contemporary world, there are many challenges that characterize the health care sector. In the United Kingdom, the health sector is characterized by wide-ranging inequalities that have affected provision and service delivery to those in need. Health inequalities, according to Gee & McGarty (2013) are the disparities existing in health between persons with different socio-economic situations, the social gradient in health. Supporting this, Whitehall studies of British civil servants- longitudinal studies/ birth cohort studies by Marmot, Stansfeld, Smith, Shipleyand Ferrie (2002) hold that there is a widening health gap, inequality / inequity, and social injustice between different groups in the UK. Hart (2006) on inverse care law holds that inequality in health is assocaited with inequality of outcome, inequality of access, inequality of use and inequality of service provision. Life course epidemiology and psychosocial impact of health inequities relate to unequal distribution of the determinants of health, and impacts on ‘choices’ people can make, both material and behavioural. At the centre of all these challenges is the public health. The public health field directly confronts health challenges such as controlling infectious disease, enhancing access to health care, reducing environmental hazards, and other health related issues. Public health policies are employed, in most jurisdictions, to tackle public health influenced by values and ideologies, need for ‘upstream’ approaches, to address the causes of ill health. In the United Kingdom, health inequalities are within the health improvement, quality, and provision of services domains of public health. The United Kingdom is one of the countries in which health inequalities are expected to be zero. On the contrary, there are some health inequalities in the public health system of the United Kingdom. One of the sectors in the country that has been badly hit by inequalities is the mental health. For instance, it is evident that black and minority ethnic communities are still facing inequalities within the mental health system (Grey et al., 2013). In response, the public health has been developing various initiatives to solve the inequality challenges. Some of the initiatives are the development and employment of population-based prevention programs, which have been seen as the great drivers of improving the general health of people. This paper discusses the contribution of public health in addressing inequalities in mental health and specifically, the discussion will narrow down to the mentally ill older people living in the United Kingdom. Background information According to Brown, Evans-Lacko, and Aschan (2014), mental health determines and is determined by an array of health and social outcomes at community, individual and even societal levels. It has a huge impact on all aspects of people’s lives. Accordingly, poor mental health significantly contributes to health and socio-economic challenges such as elevated levels of physical mortality and morbidity, lower levels of educational achievement, poorer performance/productivity at workplace, greater levels of addictions, higher rates of crime, and poor societal and community cohesion (Barry, Clarke, Jenkins, & Patel, 2013). Generally, there is a lot of confusion regarding the term mental health, as it is often misconstrued and accepted as a euphemism for mental disorder, mental illness or mental health issues. However, the concept ‘mental health’ is related to a positive state usually described as mental well-being or simply well-being. Therefore, mental health is something that all people share as well as the status of this kind of resource in communities (Allerton, Welch, & Emerson, 2011). Societies and individuals in entirety should be a major concern. However, the issue is that mental health is not proportionately distributed with those who witness the highest degree or levels of social shortcomings also experiencing much poorer mental health compared to the most advantaged members of the society. This is what is being referred to as inequality. With this, inequality in mental health simply means the uneven distribution of factors that support and protect constructive mental health, including factors that are harmful to mental health. Despite the high investment to address social challenges, deep inequalities remain in the society with the difference or gap between the poor and rich increasing. The unequal society, as well as the consequences of this to mental health, should be a big concern for all people (Hanlon, et al., 2012). It has been seen to result in an uneven distribution across different groups of mental health issues and illness and in the ability of people to recover and lead normal lives. Health care should be equitable to all population groups in a developed country. However, none of the developed countries in the world has exhibited a situation whereby people from all backgrounds have access to health care services on an impartial basis. There already exists a gap between the policy initiatives and their implementation (Grey, et al., 2013). Mental health is the soundness in one’s state of mind. Governments implement various mental health policies, which they seek to use in improving the mental health situation of their citizens (Knapp, et al., 2007). Complexity of causation All countries have been reviewing the nature of health inequalities and most of them have been exploring where they take place. In the United Kingdom, inequalities exist in the mentally-ill older population. There are many reasons why such health inequalities exist amongst this population. A good number of these reasons are often alluded to in policy documents, although they tend to be underlined deeply in background papers. To begin with, inequalities in mental health in the United Kingdom are thought to emanate from an intricate interaction of a number of factors. Those who are most disadvantaged in the society are the ones who are most susceptible to inequalities in mental health, as are provided with fewer opportunities to enhance their social and physical setting (Jeffery, et al., 2013). Therefore, the intricacy of causation of these challenges means that trying to solve or tackle inequalities in the mental health requires concerted efforts and actions at different levels. Most importantly, interventions are necessary at all levels from local authorities to national government, with the involvement of social groups, local communities, affected individuals and their families. As such, actions employed will differ significantly across the mentioned levels, and often call for a multifaceted strategy. The table below shows the determinants/factors that contribute to mental health Society Community Family Individual Equality versus discrimination Personal safety The structure of the family Lifestyle factors (alcohol intake, diet and exercise) Levels of unemployment Housing and access to open space Dynamics of the family (eg. High/low expressed emotions) Attributional style (how events are understood) Social coherence Economic status of the entire community Genetic makeup Debt versus financial security Education Isolation Intergenerational contact Physical health Provision of health care Neighborliness Parenting Individual relationships and responses Source: (Grey & Others, 2013) From the table above, it is obvious that there has been enhanced recognition on the wider determinants of mental health, particularly with increased application of the social construct of health to the field of mental health. This recognizes that attaining positive mental health calls for a higher emphasis on environmental and structural factors that generate conditions of discrimination, poverty, and eventually, inequity. Policy frameworks Improving the health of poor people According to Lloyd-Evans, Mayo-Wilson and Harrison (2014), activities that are beneficial to overall health also have a positive effect on mental health. In the last decade, the United Kingdom and devolved government policy on improvement of public health have emphasized traditional approaches to promoting health in mentally-ill old people. The stakeholders are executing this through promotion of healthy lifestyles, such as increased levels of physical activity, healthy feeding, drinking moderately with no room for smoking. The UK government has achieved this through increased investment in specific policy initiatives and social marketing campaigns that encourage the change in individual health behavior. A good example of these initiatives is the Keep Well Initiative in both England and Scotland (Hart, 2006). These initiatives have also been supported by many other national policies, such as the ban on smoking, and others that recognize inequalities by specifically directing the campaigns at the old people living in the areas that are inhabitable. Narrowing the health gap The public health has taken urgent actions to reinforce the link between the national strategic plans and the exact situation or realities on the ground. In fact, the tools of health inequalities intervention developed by the public health provide a mechanism for primary care trusts and local agencies to identify the magnitude of their local gap in order to quantify the effect on that gap of critical interventions on matters such as smoking and alcohol taking, as they pose challenges to mental health. Reducing the social gradient in health Programs such as the Sure Start and the Family Nurse Partnership are working to reduce the social gradient in health through ‘progressive universalism’. This approach delivers superior health services to disadvantaged groups such as the mentally-ill older people and offers them opportunities to improve faster (Marmot, et al., 2002). This approach has been successfully used to reduce health inequalities between different social groups. Also, wider structural changes affect the context of public policy, via their effect on the policy implementation. Over the past decade, the reorganization of NHS has reinforced their ability to provide effective services and enhance population health. Context for public policy The continuing efforts by the public health to tackle health inequalities depict their place as part of a broader alliance to promote social justice. Alleviating poverty, tackling disadvantage and addressing inequality are key approaches used by the public health. It has also offered a more favourable environment in which to act on social and health policies. Context is very important and where individual programmes and policies operate in a more favourable setting, each single developmental aspect contributes to success across the entire policy area (Gee & McGarty, 2013). Based on the experience of the Nordic countries, a favourable environment enhances the probability of success for social and health policies on issues. In the UK, public health has framed public policy against an obligation to Universalist policies based on entitlements, equality of rights and reduced levels of social exclusion. In the UK, building an environment for efficient public action has mainly co-existed with other aspects, notably the influence of the private sector and the market. The outcome has been paradoxical. For instance, on one hand, there have been improvements in health standards for people in disadvantaged areas and groups, partly due to effective public policy initiatives. However, narrowing the gap between some of the disadvantaged groups, the process has proved challenging. This is evident in the broadening of income inequalities, which significantly contributes to inequality. According to the Acheson report, equally, a strong environment for public policy action always does not mean that such policies, which support a lessening of health inequalities, successfully end up solving the issue (Linsley, Kane, & Owen, 2011). At times, they can have the opposite impact. As Hart (2006) indicates, the drive for health enhancement can result in an ‘inverse care law’ impact where the merits of such programs accrue to those that are advantaged groups because they know how to sue the system well. Furthermore, in disadvantaged areas, the reach of public services can be minimal and less able to counter this Impact. The consequence is that overall enhancements in health can easily mask continuing inequalities. Whilst enhancing the health of the people is given priority, the likelihood for differential health outcomes and mixed messages is very clear. Healthy Policy The UK government has a health care policy that continues to emphasise effectiveness and efficiency in the NHS, whilst at the same time placing a lot of emphasis on equity. Klein (2000) holds that the values of modern-day policy are likely to entail elevated public expectations that will be challenging to balance against pressure to keep down associated expenses or costs. Mainly, this tension is perceptible in the UK NHS Plan that emphasises the significance of achieving public expectations for health care, although it falls short of covering the expenses or costs associated with long-term care for mentally-ill older persons. This deliberation has been widely condemned by organisations that support mentally-ill old people, such as Age Concern. This is because it contravenes the recommendations of the Royal commission, specifically on Long-Term Care. The decision also differs from the position of the Scottish Parliament on long-term care for mentally-ill older persons. Nonetheless, the introduction of Trusts and Primary Care Groups is a vital initiative to support and promote a primary-led care, and enhance the functions of professionals, particularly at the operational level. Similarly, the reduced responsibility of Health Authorities depicts a centralisation of monitoring and strategic planning of standards. These kinds of reforms have connotations for the implementation of approaches to tackle inequalities existing in mental health and the scope of action, particularly at the local level. Potential interventions/actions to address health inequalities Dahlgren & Whitehead’s model of determinants of health sets out four levels, hence the UK initiatives to tackle health inequalities are directed at these four levels: Strengthening individuals This includes providing advice on benefits of exercise, healthy eating, smoking cessation, and alcohol consumption. The limitations of these approaches are that they insufficiently consider the constraints on people living in disadvantaged circumstances. Untargeted health education messages can actually increase health inequalities and the ‘health gap’ because of differential uptake by more advantaged groups. Many lifestyle approaches fail to recognise the context within which disadvantaged people live. Unhealthy lifestyles are often symptoms of inequalities as much as causes, and can be seen as rational responses to the chronic stressors experienced. Strengthening communities Individual social support and community social cohesion are important in protecting health. Policies & programmes, which promote these, and reduce social exclusion of disadvantaged groups and communities, are an important part of strategies to address health inequalities. Evidence shows that success involves community/citizen involvement, tackling the social economic issues, improving employment and reducing poverty rates, adequate resourcing, and sustained commitment. In Wales, the Health Authorities have been abolished to strengthen responsibilities of Local Health Groups. The local health groups are responsible for priority setting and strategic planning, as well as implementing of appropriate policies. The initiative of the UK national Assembly to modify the R&D strategy and to institute a different funding source to focus mainly on Assembly priorities is a very significant aspect in shaping the decentralized agenda. In this case, the concept of ‘earned autonomy’ set out in the NHS Plan by the UK government is an innovative way of managing this kind of tension. In addition, the Acheson Committee recommended the development of ‘pace of change’ policy to help in targeting resources at local health groups that are very far or located far away from their target (Graham, Griffiths, Tillotson, & Rollings, 2013). Improving Access to essential facilities and services Normally, the lower socio economic/ disadvantaged groups, such as the mentally-ill older people experience more barriers to accessing service. The barriers include; time, cost, distance, and knowledge. To solve these challenges, public health has managed to put some facilities and services in areas of greater need. The public health also ensures that there is equitable access to essential goods, facilities and service, such as food shops/ supermarkets, leisure, open, natural spaces, safe environment. In the case of the mentally-ill old people, the public health through Local Health Groups have been helping to minimize inequalities through developing multi-sectorial strategies (Barry, Clarke, Jenkins, & Patel, 2013). They unusually distribute and allocate staff to all homes in their areas of operation to help the mentally-ill old people go about their business normally. In fact, an important aspect for assessing the pilots is the way their staffs are distributed in varied parts of the country as well as the consequences of this for fair and equitable access to health services. Encouraging macro - economic and cultural change According to Bekkum and Hilton (2014), local, national and international policies influence the distribution of many of the determinants of health including distribution and social justice. In this case, the public health employs different strategies for narrowing income inequalities and redistribution, such as tax reduction on the basic things they buy, welfare benefits and pension entitlements (Sim & McKee, 2011). The government also has an extensive plan for equitable distribution of resources for public services. That is, every person is treated equally when it comes to public appointments and not based on his background and well-being. The UK government has also been enacting legislations that affect employment conditions, planning, housing, environment and food production. The UK government has also established a modernization agency as part of the NHS Plan, and is responsible for supporting ‘healthy’ communities by collaborating with stakeholders to develop efficient ways of enhancing health, particularly in the areas that are most deprived. The NHS strategy depicts dedication to multi-sectors, locally-based partnerships that target geographically defined areas of greatest poverty or areas that are highly deprived. On the other hand, the allocation and distribution of resources, particularly to health authorities, is linked to their attainment of centrally determined national objectives and targets. The minister also highlighted tackling health the existing inequalities amongst all groups. The initiatives set out to achieve this course included: The Healthy Schools Programme for Children of the mentally-ill old people The Welfare Foods Scheme Health Action Zones The Personal, Health and Social Education framework. Also included are the numerous aspects of the NHS Plan, especially those published in 2000, such as the Taskforce for mentally ill old people and the new National Service Framework for affected children. In Scotland, the government launched an initiative known as Health Profiles in every constituency to help solve the existing problems in health inequalities. These profiles contain important information, particularly on health care and illness, poverty and prosperity, safety and crime, deaths, educational attainment, lifestyle behaviour and physical functioning. In short, the aim of making such information available to many people was to engage decision makers, especially at parliamentary level, in a continuing analysis, which would lead to action and eventually, improved health for all disadvantaged groups such as the mentally-ill old people. In recent years, there have as well been a number of events, which have played an important role in tackling of the existing health inequalities in the United Kingdom. They include: The Action Committee on Resource Allocation The UK government first established the Action Committee on Resource Allocation (ACRA) in 1998. The committee managed to publish their first report one year after being established. ACRA covers an array of policy sphere, such as living standards and income, in particular, tackling social exclusion and low income; education; crime in the homes; employment; and public health measures. The important thing is that resources are supposed to be targeted at those in dire need of the aid. The ACRA Committee was able to draw a distinction between ‘unavoidable’ and ‘avoidable’ inequalities in health (Haddad, Butler, & Tylee, 2011). According to the committee, the term ‘unavoidable inequalities’ depicts unfairness about existing variations in health, whereas ‘avoidable inequalities’ shows that policy action can actually make a difference. In addition, avoidable inequalities are more responsive actions within the health care system, although actions at a wider level have been proposed in British policies so that things such as ‘unavoidable inequalities’ are also resolved. The evidence base of policy Friedli (2013) indicates that the aim of raising standards in mental health relies more on new initiatives in information and data collection and is connected to the goal of reducing inequalities in mental health. It has also been proven that outcome measures may be seen as a tool for monitoring inequalities in mental health. For instance, the National Service Framework requires the responsible health agencies to produce local health care needs plans for tackling the existing inequalities (Pryjmachuk, Graham, Haddad, & Tylee, 2012). In addition, the implementation of the NHS Performance Assessment Framework, Health Improvement Programmes, as well as the establishment of NICE, are all recognized as having a critical role to play in minimizing the existing inequalities in mental health since the quality of care received is subject to evaluation and monitoring (Guy, Loewenthal, Thomas, & Stephenson, 2012). However, Bekkum and Hilton (2014) hold that the Performance Assessment Framework of NHS, while identifying vital elements of regional variations is inadequate in itself to evaluate and monitor inequalities of treatment outcome, as it completely fails to take some aspects such as ethnic and socio-economic factors into consideration. Public Health and health promotion The UK government has set up some Health Improvement Programmes including strategies to develop mental health and reduce inequalities. These programs also enable wide emphasis on the economic, personal and social dimensions of health inequality amongst mentally-ill old people. In the case of Wales, the Health Plan emphasises the significance of public health and health promotion, and draws attention, particularly, to the presence of a strong team for promoting health. Wales has proposed a review of the public health function in order to enable the UK Assembly to assess how the public health function can effectively be integrated in strategies for reducing inequalities in mental health-care. Public participation The UK government has established the Public Involvement Framework and has a wide-ranging responsibility for the public in planning and decision-making, access to information, scrutiny of health services as well as exercising rights of redress and complaints. However, this comes with a share of challenges (Gee & McGarty, 2013). The involvement of the public in health care symbolizes a major paradigm shift as well as a challenge to policy-makers and professionals. The major conflict that is likely to arise will be around the allocation of resources. This is because the public voice will eventually become more influential thus posing challenges to both the National Assembly and Local Health Groups forcing them to take their issues into consideration particularly in developing both short and long-term approaches to reduce existing inequalities in mental health. The challenges of tackling Health inequalities Health inequality arises due to the existing inequalities in society, in the environments in which people live. In health, there is a ‘social gradient’; the lower the position of a person in society, the worse his or her health will be (Great Britain National Health Service & Great Britain Parliament, 2012). In the United Kingdom, socioeconomic inequalities have widened since the mid 1960s, and this has resulted in wider inequalities in health, with rates increasing most amongst those from impoverished backgrounds. This aspect of deteriorating health inequalities, in relation to mental health, is more marked for older women. This is when the socioeconomic position, in terms of education, is considered. In short, over the last ten years, the progress on health inequalities can be summed up as having achieved a lot, but much still needs to be done (Friedli, 2013). The experience against the target set by the public health makes this vivid; there have been enhancements in terms of longer life expectancy for the selected group, but the gap between groups that are highly disadvantaged and the remaining part of the population has remained unchanged. In fact, the current data shows that the gap or inequality is no narrower compared to when the public health first set the target. Recommendations and Conclusion In an appraisal in the UK Public health Services, it emerges that the present status in mental health is attributed to the failure of public services to specifically prioritize preventative approaches necessary to completely break the cycle of low aspiration and deprivation. For instance, the ‘Failure demand’– the demand on public services that could have earlier been avoided by preventative measures –as well as of a system which is highly reactive and targets the outcomes not causes of inequalities. Thus, the challenge can be solved by prioritizing preventative services with an emphasis or focus on tackling generational inequalities. As it has been seen in the discussion, mental health, particularly for mentally-ill old people in the UK suffers from inequalities that other health sectors also witness. From the discussion, the mental health suffers from skewed allocation of resources, social and economic disadvantages. Bad policies are mainly blamed for the challenges facing the mental health sector. However, the government has in recent years been attempting to address the issue. It has proposed and enacted a number of policies that play a critical role in solving the issue. Also, in some cases, the sector has been decentralized. Decentralization is accompanied with the formation of Local Health Groups that link directly with those people who are affected. Other endeavours to solve the problem include the establishment of feeding programs for the identified people and their families. It must be noted that poverty and poor lifestyles also contribute to their poor state of health. Thus, the stakeholders have come up with approaches to help these people stop smoking and drinking alcohol. References Allerton, L. A., Welch, V., & Emerson, E. (2011). Health Inequalities experienced by Children and Young People with Intellectual Disabilities: A review of Literature from the United Kingdom. Journal of Intellectual Disabilities, 15(4) 269–278. Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health, 13(1), 1-19. Bekkum, J. E., & Hilton, S. (2014). 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