Tackling health inequalities: Three lessons for gaining public support

Georgina Culliford carried out in-depth research for the NHS into a scheme aiming to direct healthcare resources to the people most in need. She shares her insights into how to get people onside with a potentially controversial project

Covid-19 has thrown into sharp relief deep-rooted inequalities in UK health care. Vulnerable people and poorer communities have suffered disproportionately during the pandemic.

So Sir Michael Marmot’s 2010 landmark study of health inequalities has never been more relevant – as his 2020 post-Covid update makes clear. The Marmot Review proposes that healthcare resources are allocated on a ‘sliding scale’ based on deprivation and need; the greater need, the greater share of the pot. He coined this ‘proportionate universalism’.

But how to apply the principle to real policy, real people? The NHS and local authorities in Leeds recently launched an ambitious framework to do just that.

Before they introduced the plan, NHS Leeds CCG worked with us at Qa to answer a key question. How would the city’s residents react to the idea of the unequal distribution of healthcare resources?

We undertook a piece of research that provided qualitative insights on Leeds residents’ views.

Here are three key lessons I learned about how to communicate the strategy in a way that got the public on board.

1. Visualising a concept aids understanding

Free healthcare for all is the cornerstone of the NHS. So how to introduce the idea of equity in a system that prides itself on equality?

We used this cartoon to illustrate the differences between equality and equity; that people’s health does not start on a level playing field. Throughout the focus groups and interviews we held with the public, this proved a really effective way to get the concept across.

Most people were highly supportive:

  • once they understood why equity and proportionate universalism were needed, and
  • once they were assured that their own access to key NHS services would not be affected.

Lesson: Use images to communicate the reasons why a specific approach is needed, particularly when dealing with a concept which is not widely understood, like equity. Make efforts to reassure people that their own access to key services will be unaffected.

2. Each local area is different – get to know your people, postcodes and politics

Each city and neighbourhood comes with its own pockets of wealth and deprivation. In Leeds, some of the most affluent postcodes sit back-to-back with areas with the highest level of deprivation in the country.

Through open discussion with residents, we learned that pitching this strategy in terms of the wealthy areas subsidising the less well off areas could risk reinforcing local stereotypes and divisions. That could create an ‘us and them’ culture, rather than focus on a unified community effort.

Language was also important. While policy often refers to ‘deprived’ areas (based on the Index of Multiple Deprivation), labelling a community or postcode as deprived was alienating and insulting to people who live in these areas and take pride in their community.

Lesson: Talk to the people in your communities, so you get to know what language, divisions and stereotypes to avoid – and which to tap into for successful communications.

This project was presented at Social Research Association event on health inequality – watch above

3. Human stories can overcome ingrained attitudes

Most people backed the proposal to direct more health resources to those in greater need. However, some struggled to support the idea, saying it was wrong to give more to those ‘unwilling to help themselves’.

In other words, does everyone ‘deserve’ this extra help?

In reality, multiple complex factors contribute to any kind of inequality. Health outcomes are linked to housing, income, mental health and so much more. But this isn’t always easily understood by the general public.

Humanising the concept, by giving real life examples of people who live in the same town, allows others to empathise – and understand why the extra help is needed, and fully deserved.

Lesson: By telling real-life stories, local authorities can take an abstract and sometimes controversial concept like proportionate universalism, and show that it really is needed and can make a difference to real people’s lives, right in their home town.

These three lessons helped an ambitious strategy like the one in Leeds land positively when launched, by connecting authorities with their population’s views on health inequality.


Georgina Culliford is Senior Research Executive at Qa Research

What we do: Health and social care

Qa Research undertakes a wide range of research, insight and evaluation studies for organisations operating within the health and social care sector.

This includes Clinical Commissioning Groups, Public Health teams, private hospital brands, charities and NHS Trusts.

We offer a wide range of services including public consultation, patient satisfaction surveys, PROMS studies, service design and co-development, digital transformation and inclusion studies and much more.

Find out more about the work we’ve done within the health and social care sector by contacting Richard Bryan on richard.bryan@qaresearch.co.uk

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