INTRO RAP: [00:00:00] Stories, labels, Misconceptions NHS remains a blessing Created in 1948 We want it to remain great A podcast where we share our stories Explore solutions in all their glories They say it's broken, but it's not done With your host Val Barrett Dr. Jeremy Anderson

VAL: we often talk about the NHS being for everyone, but is it really? What if your postcode, income, ethnicity, or even your accent determine how healthy you are? Or how long you live

VAL: I'm Val Barrett and I'm joined as always by. Dr. Jeremy Anderson, who is a [00:01:00] clinical psychologist who works within the NHS. Welcome to Stories, Labels and Misconceptions. We are doing a health inequality series. This is part one of multi part series of six. 

DR JEREMY: In today's episode, we're beginning a new series, looking at health inequalities in the UK, what they are, how they're measured and why some communities are systematically left behind. 

DR JEREMY: The first thing to think about before we talk about inequalities what is health generally although health is one of those words that we use all the time, it's actually surprisingly difficult to define. And it's had several different definitions over the years. So for a long time, we used to just think that health, like to be healthy is just to not have a disease or an injury. 

VAL: Yes. Yeah.

DR JEREMY: If you didn't have a cold, you were healthy, right? Or you didn't have cancer, you were [00:02:00] healthy. If you didn't have a broken leg, you were healthy. 

Yeah. 

DR JEREMY: But when you start, I get that. There's more to it than that. So maybe you don't have a illness or an injury, but if you cannot do a push up.

VAL: Yeah. 

DR JEREMY: Compared to someone who can.

VAL: I'm in that group.

DR JEREMY: Then maybe you're less healthy than someone who can.

VAL: True. 

DR JEREMY: So health , is a part of it is not having an illness or injury, there are healthier ways of being in the world, whether you have an illness or an injury or not. For example, people with long term health conditions. There are ways for those people to be healthier or not. And beginning in 1948, the World Health Organisation came up with a new definition of health. They talked about physical, mental, and social well being, not merely the absence of disease

DR JEREMY: It breaks with a biomedical model of disease. We started to see the biopsychosocial model of health or disease. [00:03:00] Biology is part of it. But psychology and your social setting is also part of what constitutes health.

DR JEREMY: It's a vague definition, now it raises the question what is wellbeing? And the point is that, health can have several different definitions, but it does refer to this notion of well being, especially associated with normal functioning, the absence of disease or absence of pain, but it also includes mental pain or injury. And when you think about health more broadly, what does it mean to be healthy? There's a lot of different things that contribute to whether or not you're healthy. So I don't know what do you think, contributes to health? 

VAL: When I look at social health, it's about your ability to interact with others.

DR JEREMY: Exactly. 

VAL: It could be about where you live, how you live, how much [00:04:00] you earn. 

DR JEREMY: Yes. 

VAL: We know that throughout the series, we're going to touch on things like, income inequality, postcode inequality, that impacts outcomes. 

DR JEREMY: Someone might say, what does income have to do with health?

VAL: Has a lot. 

VAL: It has a lot to do with health. 

DR JEREMY: I think it does because the kind of income or job you're doing, has to do with, the working conditions. If you work in an office, you have a different kind of, exposure to things that affect health than if you're a coal miner. So the physical environment you're working in, the social environment, whether you feel supported by the people around you, the kinds of relationships education and literacy are important, if you can't read the prescription on the medication bottle, it's difficult to keep yourself healthy,, 

VAL: average age of an adult in this country. Average read an age is age 12. 

DR JEREMY: Yeah. [00:05:00] That sounds about right. 

VAL: Something like that. Yeah. So it is pretty low. 

DR JEREMY: Yeah. All these social. Educational, occupational, physical environments we live in, as well as things we can't change our biology or genetics,

DR JEREMY: yeah. We've talked about sickle cell disease on this podcast a lot. That's a genetic condition. People are inheriting that. There's nothing they can do to change that. There are treatments for it now. But there's, people's ethnicity or , their genetic profile can put them at, Increased risk for certain health conditions, or affect their health.

VAL: We're going to get into that in episode three. So let's just stick to what is health. I think we've covered that. That is not just physical, mental, social. Being. 

DR JEREMY: Yeah. I think so. It's not just 

VAL: People only see doctors when they're in extreme pain. 

DR JEREMY: [00:06:00] Absolutely. And some factors people don't have control over and some of these things people do have control over. 

VAL: Yes.

DR JEREMY: When I was training, the number one killer, was heart disease And now it's cancer, , but that came about number one, because people were living longer. Part of it was the treatment for heart attacks got better, but also we realised that factors like diet and exercise were crucial to reducing the incidence of heart disease. So the incidence of heart attacks and stroke went down.

DR JEREMY: People aren't dying of heart attacks, they're living longer, as you get older, your risk of cancer goes up. So at the same time that we were, lowering people's risk of cardiovascular disease, more and more people are just living long enough to get cancer.

DR JEREMY: Cancer has overtaken cardiovascular disease as the number one killer. 

VAL: When I had my heart attack, I was in shock because a, I'm not obeist, b, [00:07:00] I was going to the gym. Okay. I wasn't eating the letters every single day, but I wasn't eating a takeaway every single day. When I read all the information about who's likely to have a heart attack, I didn't fit into that box.

DR JEREMY: I once had a friend in Canada who came from a family of six brothers five of his brothers had all died by age 35 of heart disease. Now that's extremely young and it's , the men in his family were very prone to cardiovascular disease. He was the only one lived past 35. It wasn't necessarily that they were, eating, pizza and fried chicken every day, 

VAL: a burger.

DR JEREMY: Yeah. 

VAL: What are health inequalities? 

DR JEREMY: Yeah health inequalities. This is my AI overview because it's been 20 years since I cracked a textbook on health psychology. Obviously, there's, different determinants of health and social determinants. [00:08:00] Determinants of health. And health inequalities are specifically the avoidable or unfair differences in health outcomes between different groups different groups of people, You can see that, they won't have exactly the same health outcomes and there's many different factors involved, some of which are controllable, some not, but at least in ones amongst the ones that are controllable, there are different, social policies or government policies, or structures within a given society that can either exacerbate those differences, or can lessen differences and make them, more equal, right? When we talk about inequalities, it's important to think we're not claiming that everyone must have exactly the same health outcomes. But among the determinants of health we have some control over, we want to make sure we're doing something to make it better, not worse.

VAL: When we look at, different [00:09:00] groups. . You're more likely to live longer in Kensington and Chelsea than in Blackpool. 

DR JEREMY: Okay. ~Yeah. ~

VAL: Irrespective of how you probably take care of yourself, sometimes the factor is determined on postcode.

VAL: Accessibility to good health care. 

DR JEREMY: Yeah. So a geographical difference, right? Literally where on the map you live has an impact on average, how long people in that area live, right? It doesn't mean that every individual is going to. Not live as long or live longer or whatever it just but just on average, it means that people living in that area, maybe don't live as long or don't have as good health outcomes. The question is, what factors contribute to that difference? Maybe if people in one area, you've got access to healthcare, if you have to travel further to access healthcare,

DR JEREMY: you have access, but it's not equal if you have to jump through more hoops. To see a GP, [00:10:00] get to a hospital, or get to an A& E, or the ambulance, wait times are longer, that will have, over time, in, in aggregate, that will have an impact on people's health, ~right?~

DR JEREMY: If, people in one area. Live next to a, I don't know. An industrial plant. So , it pollutes the water, right? If you're drinking water is contaminated, that's not as clean. You're exposed to things that impact health, if the air quality is poor, you're probably going to have more cases of asthma obstructive lung disease or even preventable deaths from respiratory conditions.

VAL: Yeah. 

DR JEREMY: Some of these things are not preventable, but some really are. 

VAL: But we look at areas that are deprived. 

DR JEREMY: Yeah. 

VAL: Kensington and Chelsea, People have the assumption that is a very affluent area to live. Yeah, it is. The South of the borough is, [00:11:00] when you go to the North of the borough, when you go to Notting Hill, Labroke Grove, you've got that long road, half of it, the neighbourhood is deprived the other half isn't, but it's still on that same road. So it's that road leading towards Holland Park and Notting Hill. As you can imagine, the house prices are high. You've got the rich living there. So a lot of health inequalities is not just postcode. It's pockets of areas that are deprived within that postcode, 

DR JEREMY: right? 

VAL: Because one thing people will say, oh, you live in Kensington, Chelsea, and they think everyone's rich. No, there are areas, pockets of deprivation.

DR JEREMY: Absolutely.

VAL: Deprivation in the London borough of Kensington and [00:12:00] Chelsea. People seem to think that because I think it's the majority is wealthy, that kind of drowns out the fact that there are small pockets that are not so wealthy.

DR JEREMY: The word deprived or deprived borough, it is a very uK like before coming here, I never heard of that. 

VAL: We like to use words like deprived. What else is my hateful word? Hard to reach. 

DR JEREMY: Hard to reach. 

VAL: I hate that bloody word. Have you heard of that word? 

DR JEREMY: The expression of someone who's hard to reach, what does that, 

VAL: When they write all these reports and they say certain section of society, they're hard to reach bloody hard to reach, where people are.

DR JEREMY: I can

VAL: always put the emphasis. on the people just like bed blockers, their fault that on a ward is always the word is put on the emphasis [00:13:00] of the people. So when government or local authorities say, Oh that group is hard to reach. We're trying to provide the services, but the hard of it forever is a traveling community. Ethnic minorities, learning disability groups, they say we're hard to reach, no, you have to meet them where they are. They shouldn't have to meet you where you are. 

DR JEREMY: Yes, exactly. 

VAL: The ones providing the service. When you write, this area is deprived, it's deprived because you've deprived it. You have starved it of essential services that it needs to help the community to have better health outcomes, educational outcomes, all this impacts on people's lives. 

DR JEREMY: I've honestly felt a bit confused when you asked the question because I've never heard the term hard to reach referred to a group of people like when I, my understanding of the expression hard to reach, it would be like, if someone [00:14:00] doesn't answer their phone when you call them, they're hard to get a hold of.

VAL: They're ignoring you. 

DR JEREMY: Yeah, you're hard to reach. And maybe that, that really is on them just not want to talk to me, but in terms of describing a whole group of people as hard to reach. I think there's a problem when the onus is put on the people being served to do the reaching.

VAL: People don't access services. 

DR JEREMY: Yeah. 

VAL: Ethnic minorities least likely to access. Do you know how many service doors I've banged on? 

DR JEREMY: Yeah. That's, and 

VAL: I don't receive, but they say I'm not accessing. I'm accessing, so I'm not receiving. What do they mean by accessing? What do they really mean? Because if it means, do I know where that service provider is? The answer is yes. Have I been in touch yes. Have I received services from said service provider? The answer is yes. Bloody. No. So why say I have an issue as a person [00:15:00] of colour accessing services? I don't. The issue is you are not providing the services because you always come with barriers or you can't have it because X, Y, Z,

DR JEREMY: So let's give an example of, someone, they come to this country and they don't speak the language. So they've got a GP surgery area, they're registered, but they don't really understand what they're being told. They may be educated. They understand, written language, but maybe not in English. These are barriers to accessing and, I guess that person is hard to reach, because the services are not offered in the language. So let's say someone comes from France and 

VAL: yeah, 

DR JEREMY: There should be French translation or signs 

VAL: It costs a lot to have services translated into various languages. I'm not saying it's right or wrong. I'm just saying there's a cost. And I worked at, in the [00:16:00] NHS and, we had a policy that we didn't allow children to be the translator for their parents.

DR JEREMY: Okay. 

VAL: Often When it comes to health, as yourself, there are words that are used that are complex. Does a child understand that word? What do we know that they're actually translating it, that the information is absolutely correct. Do you see what I mean? So we would have to get a professional translator in, because , nine times out you'll have families going to the GP. Bringing their children along to be the translator. 

DR JEREMY: Maybe we should spend more money or with the advent of AI, this might be a problem that could be solved. 

VAL: Exactly. This money is spent there. So it's like, what is priority? We know the waiting list is long. We know that through COVID [00:17:00] they're probably still playing catch up. And we know that people were probably living in had cancer, weren't being treated. So there are still a lot of issues. Each borough or each NHS trust provides language services. Yeah. Whether they will cut back on that. Because they need to provide more social care. Don't forget every part of healthy starving.

VAL: We're going to be losing workers soon in social care. We'll have to cut back what are they willing to sacrifice?

DR JEREMY: Today, my wife was reading an article from the Guardian, the Labour government is postponing their child poverty initiative.

VAL: Yes, saw that. 

DR JEREMY: They just don't have enough money to pay for it, right? A key plank of their manifesto, right? This is actually relevant to health because early childhood [00:18:00] development and poverty in early childhood has a knock on effect throughout the person's life. These, as, it's always kicking the can down the road. It would be cheaper to deal with it now. It just costs more money later. 

VAL: We know that, but we're going to be talking about common sense solutions.

DR JEREMY: Yes. 

VAL: In part five. It sounds easy, but why can't it be easy? Why can't it be black and white? This area is deprived. We know in areas, like Kensington, Chelsea. People live longer. I'm going to be around for a long time. Blackpool, they don't live as long. How can we get Blackpool to be like Kensington, Chelsea? What is going on in Kensington, Chelsea that Blackpool doesn't have?

DR JEREMY: To have a deprived borough and a resourced borough, that is a choice. In how we structure our societies. So if we want to have [00:19:00] some areas that get the resources, because it's based on their local, I don't know, their tax base. Versus saying, we want to share the wealth and make sure that it's a consistent level of coverage, no matter where you live. That's a choice we make, right? An example of this is, with schooling, you could say that you pay for schools by, I don't know, property taxes, so expensive real estate means better schools for the people who live there.

DR JEREMY: The rich people get good schools and the people who don't pay a lot of property tax because their property is not worth as much. Get bad schools, right? Yeah. Or you could put all the tax money into a central pot and make sure that all schools get similar funding. That's a choice governments make. I think it's the same with healthcare. 

VAL: Put it this way. When we look at local authorities, 

DR JEREMY: yes. 

VAL: When Grenfell happened, in Kensington, Chelsea, [00:20:00] Kensington and Chelsea had a surplus. They had money. It's what they had. So imagine if it happened in a deprived borough, 

DR JEREMY: okay.

VAL: That didn't have the resources that Kensington, Chelsea had. All that money spent on hotels and whatever,

DR JEREMY: So they were able to house people. 

VAL: Yeah. They were able to do things quickly, but imagine if it was a borough that didn't have. Yes. And that would completely broke like Birmingham, 

DR JEREMY: yeah. 

VAL: Suppose that happened there. So another thing we have to look at as well, how are each of these councils managing their budgets? In Kensington and Chelsea, they make money from. Parking [00:21:00] fines, where I live, you can't park until after 10 at night, unless you're willing to pay a couple of quid an hour, i've noticed certain resources are at the north of the borough.

DR JEREMY: Yeah. 

VAL: Not south of the borough. 

DR JEREMY: Even though you're in the same borough 

VAL: Yeah. 

DR JEREMY: The one group has to travel further. 

VAL: The most deprived wards in this borough are North Kensington.

DR JEREMY: Yeah. 

VAL: You'll find more resources that end of the borough. One thing I must admit, that's really good here. They've got the youth clubs. 

DR JEREMY: Yeah. 

VAL: My son was going to one. We had no problems with transport, getting him to college, getting him to school. And that. Looking after carers, they're very good

VAL: so there are things , that they do very well. I'm sure they're not all singing or dancing, but there are things that we've managed to get here that we didn't manage to get when we lived in another borough. There are [00:22:00] differences. I lived in a borough. Deemed as deprived. When we moved here, I noticed the difference. 

DR JEREMY: I've talked to patients who, if they get referred for, mental health services in the community, some of them get told, okay, it's a two year waiting list for that. Yeah. And I said, why is it a two year waiting list?

DR JEREMY: And the person just says it's a deprived area. And what that means is if it's deprived, if the income level is relatively low, those people have more health problems. They need more health. 

VAL: You would think that would be more

DR JEREMY: simultaneously, less likely to get the help they need

VAL: They're shoveling snow and it's still snowing. They're not getting anywhere because you're deprived. You need something, a service to make your health better, whether it's mental health, physical health, whatever it is.

DR JEREMY: Yes.

VAL: They're telling you there's a waiting list of so many years, which is going to make your life worse. But yet they know the [00:23:00] area is already listed as deprived, which means it's urgent. It needs resources. It's it's on red alert, 

DR JEREMY: yes, 

VAL: but for somebody to come back and say it's deprived. It's an awful thing to say. As 

DR JEREMY: if that was the explanation, it's just a description. It's just a restating of the same thing I said. Okay, it's a two year wait. And I say, why saying it's deprived doesn't actually explain it. Why is it deprived? Because it's a two year waiting list.

VAL: That isn't a reason. 

DR JEREMY: It's just a circular restatement.

VAL: Doesn't make sense. If anyone said that to me, I'd stand there and say no. Yeah, I want to know why, what are you doing to make it better? What are you doing? It just seems like deprived areas will always be deprived. This isn't new, new, this is not new. 

DR JEREMY: Yeah, nothing changes, nothing will change.

VAL: I remember a friend of mine said, don't live in a Labour borough, even if you're a Labour voter, [00:24:00] because they feel the cuts more. When there's a cut, Labour boroughs feel it more. Isn't that weird? 

DR JEREMY: Is that because Labour voters, tend to have lower incomes, 

VAL: It's just strange. It really is because the most boroughs that are deprived are mainly. Labour controlled, 

DR JEREMY: right? 

VAL: Yeah. When the elections came up, my friend said, you better pray the Tories don't get to Chelsea.

DR JEREMY: Yeah. 

VAL: Seems to be getting worse, whether it's health, lack of opportunity. Education attainment is low the only thing is high there is the crime.

DR JEREMY: Keeping the budgets for these services, by location, keeping the money in that location is a [00:25:00] way that people who have more, get more. People who have less get less. That's a very attractive system for the haves feel like their money is going to their community. They like that, and if you propose, okay, no, we're going to put it all into a single pot and spread it equally.

DR JEREMY: People don't like that, Even if you're purely self interested, you're better off living in a society that is more equal that way. Because , when people are deprived and they are suffering they are, they're unhealthy and , it leads to all sorts of problems, lack of productivity, crime, and just all these sorts of social problems that will cost all of us in the end.

VAL: Exactly. It would. Should that be at the detriment of the rich? 

DR JEREMY: I guess that's what I'm saying. It's unfair 

VAL: for them to pay extra. 

DR JEREMY: Way over the top. Even if they pay extra, that's not to their detriment. That's to [00:26:00] their gain. Because you can have all this stuff but if someone robs and stabs you, it doesn't matter how much money you had, right? That's to your detriment. If you get this massive inequality you might be very rich, but if you have to live in a fortress, and you're worried about, about, your bodyguards taking you out, then how much better off are you why not share a bit of the wealth, make the world a better place, and then everyone's freer. 

VAL: Is health inequalities just about rich versus poor? Or are there other factors at play? 

DR JEREMY: There's lots of different factors, the rich versus poor thing, that's a key factor.

VAL: Of course. 

DR JEREMY: That's obviously one, but there's so many different factors , at work. Including, I have to say, lifestyle I mentioned the Darcy report, that identified the problems with the NHS. And one of the things that he identified, and I [00:27:00] totally agree with this, is that the general public is not as healthy as it could be we don't exercise much don't eat well and we probably smoke more than we should. So there's lots of things that we could do to improve our health. 

VAL: Yeah. 

DR JEREMY: That we don't do.

VAL: It does cost a lot to go to a gym. 

DR JEREMY: It does. If you compare the rates of these things, to different countries, we're not as good as we could be. I think I was saying to you before the episode, , or maybe I'm just not remembering it. Maybe I've already said this today , the level of obesity in the UK is 30%. Okay. The level of obesity in Japan is 5. 8%. If you have a population less obese than the UK, that's a whole bunch of diabetes and other metabolic. Problems and heart disease you don't have to pay for in your health system. Yeah, so there is a role I think for lifestyle factors and if there's a role for people to play. In their own health, [00:28:00] 

VAL: but if they're not in the right mindset, if their mental health is suffering all around them, their life is bad. They don't see it. They don't see a way out. They don't see any future. They've got no hope. 

DR JEREMY: Yeah. 

VAL: How are they supposed to access services if they're not in the right state of mind? It's easy to say we should be in charge of our own healthcare. Fine. but if all these factors, poverty, low income, no income, high unemployment, Mental health, hopelessness, you're just not happy, we don't think about happiness.

DR JEREMY: Yeah.

VAL: If you're suffering from all these things, you're less likely to access all the [00:29:00] services that can help you live a better lifestyle. You're more likely to smoke. I used to smoke myself. Probably drink, could end up taking drugs, it's a factor that a lot of people are living that way. Not because they've always dreamt that's the lifestyle that they've wanted. Yeah. But because something has happened in their lives. We're not all blessed to be born into a certain household. Yeah. Where we haven't had to want for anything, that we haven't had to fight for equality. We haven't had to fight to get an opportunity to get a job, that, good health, decent home, we haven't had to fight for those things, but some people do.

VAL: Some people are born into [00:30:00] horrendous conditions. Some people don't know their parents give them up, they're sexually abused at a young age. Even before they get to that age of being an adult, their life is messed up. And the services, we know that there's a problem with children that come out of the care system.

VAL: When we look at what happened in the North with the grooming gangs, who cared about those young kids? The police didn't, so we can say all these factors until we're blue in the face. If we are not taking care of individuals before they reach a certain age, is it seven? They say, see at seven, you see the man, you see the woman, if we are not taking care of them for that age, they are more likely to go the route.

VAL: We don't want them to go. If a [00:31:00] child is being raised in a care home, once they get to a certain age, they're told to leave. 

DR JEREMY: Yeah. 

VAL: Where are they going 

DR JEREMY: yeah. 

VAL: Problems, if they've had issues while in care, have they had the resources to help with that? Yeah. So it's all right, giving them a roof and a bed. What have you done with their mental health, their wellbeing, their self esteem. And this is why it's so easy. The men like that. To pounce on these young girls, if you notice only certain type of girls, they go for the ones. That are vulnerable. Yeah. They need, love, need someone just to say, I will care for you. I will look after you. Everybody else, they've turned their backs on you.

DR JEREMY: Yeah. My statement before about, needing to make better lifestyle choices. I, at no point am I blaming people for the bad things that have [00:32:00] happened to them. 

DR JEREMY: I, sometimes, with my patients, I make the distinction between fault. Those are two words we often use as if they're the same, right? 

VAL: Yeah. 

DR JEREMY: What's the difference between fault and responsibility? Fault is looking at the past. Why did this happen? Whose fault is it? Yeah. And sometimes we say who's responsible and what we mean is whose fault.

DR JEREMY: But when you say who's responsible, you mean Who's going to fix it? What caused it and who's going to fix it are two different questions, we confuse the two because we say, the onus is on the person who made the mess to clean it up, right?

DR JEREMY: Sometimes that doesn't happen, right? Sometimes you're in a point in your life where it's not your fault. You didn't make the choice to be abused or to grow up in a certain area but it's your life and you're the only one who can change it, right? 

VAL: Yeah. 

DR JEREMY: The classic example is, if you're walking down the street minding your own business and you get hit by a car and now [00:33:00] you're in a wheelchair.

DR JEREMY: Whose fault is it? The driver who's responsible for your life. It's you, how you live your life from then on, you have to, learn to live or learn to walk again that's a tough road you didn't ask for, but you're only one who can walk it.

VAL: That takes a lot of support. That's what we're lacking. I'll give you an example. We're always told about community, we should look out for one another, but where I live, there's a man who's got mental health issues he had an episode. I called the mental health team. They know who he is.

DR JEREMY: Yes. 

VAL: But because I wasn't a relative. They couldn't do anything. So I said to the woman, he jumped in front of a fire engine. On a 999 call. He's a danger to himself. They still wouldn't [00:34:00] act. 

DR JEREMY: Because you weren't a relative.

VAL: I am a concerned neighbour witnessing somebody having a breakdown. It's not nice to see. 

VAL: So they wouldn't 

DR JEREMY: send anyone to check on him or do a welfare check? 

VAL: No. This person is unlikely to pick up the phone and say, I'm having a breakdown. Very unlikely. 

DR JEREMY: Yeah. 

VAL: So people do it for them. I'm alerting you. I'm telling you he could end up hurting himself or hurt someone else. He could have crashed. Eventually. We had to call the police. Of course, he goes to A& E. Why? It makes no bloody it's ridiculous. They know him. He's well known. So they knew who I was on about. I couldn't give information. Like [00:35:00] date of birth but they knew who I was on about. It's not like they didn't know. They knew I said, I don't need to know his history.

VAL: I don't need to know his business, but I'm informing you. This is what's going on for over a few days and something needs to be done. They wouldn't do anything. Accessing services are two bloody different things. So don't write your reports saying we don't access. We bloody well access.

DR JEREMY: The level of social support he had and the perceived social support. For people who don't know, I did a whole PhD on stress. And, one of the things we looked at is the effect of social support on stress and health outcomes.

DR JEREMY: What's really important is, perceived social support you can have , social support. But if you don't perceive yourself to be [00:36:00] supported, then you're just as stressed as if you didn't have any. So it's how well supported you feel that you are, has an impact on your stress level. And that impacts. On your health. 

VAL: It was just awful. 

DR JEREMY: Yeah. 

VAL: They're trying to, have a handle on social care, mental health and it shouldn't have to go through A& E. That's not what A& E is for. It shouldn't have to go through the police. That's not what the police are for. 

DR JEREMY: Did you hear the announcement yesterday

VAL: I love that. 10 hospital trusts, Oh, have been piloting new assessment centers to deal with people experiencing a mental health crisis. The aim is to get patients to an appropriate care, to appropriate care in a calm environment, avoiding long waits in A& E. I've even heard of people with [00:37:00] a noose around their neck sitting in A& E. How is that? 

DR JEREMY: Yeah, 

VAL: they said there's going to be 10 

DR JEREMY: 10 trialing it and they want to roll it out across the UK over the next 10 years. So they haven't done anything yet. They're just announcing this is what they're going to do. And then there is this trial.

VAL: There should be separate space. 

DR JEREMY: There should be a separate space where there are 

VAL: specialists, mental health care team, 24 seven, because person's breakdown might not be between nine and five. I'm sorry to say. Yeah. So there needs to be a separate space in all AEs. If there are any AEs left 

DR JEREMY: Yeah, I can't remember if I told this story before, I once had a patient who came to their session with me. This is back in Canada. And, they said, there's suicidal and they exclaimed that, if I let them go home, they were going to go home and kill themselves.

DR JEREMY: So at that point, it's time to go to [00:38:00] Amy. And, I might normally call an ambulance, but, happened just to be across the street from the any. So what I did was I walked the patient over to the, for them to be immediately assessed or so I thought, so we arrived and it was full.

DR JEREMY: And a very overworked, nurse or clerk when they heard I'm a psychologist, I'm here with my patient, who's telling me that they're going to kill themselves and they've already done this , they didn't quite roll their eyes, but they just exasperated. They said, okay. 

DR JEREMY: Sit over there.

DR JEREMY: When people with mental health problems show up in A& E, they do need emergency care because they're going to do something to themselves. But from the point of view of the A& E staff, they're looking at this we've got people who want to live and are dying and we need to help them right now. We don't have time for people who are doing this to themselves. 

VAL: We have spoken about health. 

DR JEREMY: Yeah. 

VAL: Health incorporates not just physical pain, 

VAL: Mental pain. 

DR JEREMY: And 

VAL: They should be seen, 

DR JEREMY: they should be. And maybe the exasperated, [00:39:00] nurse surgeon doesn't need to be doing that, but they do need to have dedicated services that can see them urgently because that is an aspect of health care that is an unmet need.

VAL: So we've talked about the main drivers, poverty, housing, education, no money, no hope. We've looked at rich versus poor. We know that it's much bigger than that. It's very complex which is why I think government after government, haven't got a grip on health in this country social care seems to be the hardest one. 

DR JEREMY: Yeah. 

VAL: So it's not as cut and dry as people think take politicians out of the picture, hand over the department of health to clinicians. It's not working in [00:40:00] politicians hands.

DR JEREMY: Solving complex problems, starts at the beginning. You do one thing. And you take care of that and then move on to the next when looking at the social determinants of health, I found a pie chart that looked at all the, is looking at all the factors that contribute to individual health.

DR JEREMY: And according to this pie chart, it's only, 10 or 11 percent of your health that's directly related to the medical care you receive. There's all these other factors that contribute to your health.

DR JEREMY: Yes, there's a role for government and funding in the NHS. But there's a whole lot of other things that are contributing to people's health that need to be tackled from different angles. So you can't solve it all, all at once, but you can do a kind of a piecemeal approach of little by little taking a bite out of this and a bite out of that and gradually things improve.

VAL: But also something we mentioned, we did an episode on prescription. Charges. So if you're living in a deprived [00:41:00] area, earning over the threshold you have to pay for your medication.

VAL: People with asthma have to pay for inhalers and everything. And if a mom, children, she's just about managing, but she's going without her inhalers in order to feed herself and her kids. She's more likely to get ill. The health inequality also covers prescriptions to keep you well, to keep you out of A& E.

VAL: Yeah. I don't know, it's complex. I don't work in health. I'm going to think about it as a layman. There just seems so many things that could be solved.

VAL: People in the poorest areas live seven to nine years fewer on average than people who live in a [00:42:00] rich area. Yeah. Affluent. 

DR JEREMY: That's on average. 

VAL: On average. 

DR JEREMY: Yeah. 

VAL: When's the last time you saw a person who's obeist who's rich? 

DR JEREMY: I'm trying to think 

VAL: it's quite rare. 

DR JEREMY: No, you don't. I can't think of it.

VAL: They can buy better healthcare. 

DR JEREMY: Yeah. 

VAL: They can get access to. They're slimming pills without having to sit there waiting for the NHS.

DR JEREMY: True. 

VAL: They can buy better food, better, everything's better, better skincare, better this, better that. 

DR JEREMY: So money 

VAL: does give you access to better healthcare. ~It ~

DR JEREMY: I was wondering if, Warren Buffett. Do you know who that is? 

He's, 

DR JEREMY: He's very old now. He's a billionaire investment guy owner of Berkshire hathaway. 

VAL: Everyone's looking trim since 

DR JEREMY: everyone's looking trim.

VAL: Slim and trim. Look at [00:43:00] Oprah. All the years she tried to lose weight and all of a sudden spokesperson for WW this magic injection or pill comes in and all of a sudden the woman trim and fine. Come on. You're rich or have available funds.

DR JEREMY: That's funny because we call rich people fat cats, but how many fat billionaires are there? You can't call them that 

VAL: My biggest gripe is when they take it. And then they go on TV, lecture us and say how bad it was, don't take it, but you are the size you want to be, you've lost your weight ~now.~

VAL: That's going to bring down the risk of obesity, heart disease. The risk, if you're having a stroke and all those things, that's what they say, I remember this movie. I can't remember what it's called. remember the name of it, and I'll ugly's they were [00:44:00] divided into people that look good and people that didn't look so good.

DR JEREMY: Okay. 

VAL: It was with Jolie King. These futuristic movies in the future. And it was about them. I think they had to take a pill or some something and they become beautiful, , 

DR JEREMY: they look good and healthy ~or ~

VAL: but the whole point is we seem to be having people that can access that magic. Let's call it a magic potion. 

DR JEREMY: Yeah. 

VAL: Everybody wants it, but if you haven't got the money, you can't get it okay. And you've got to be , a certain BMI, but yeah, if you're near that and could do with it, you're not going to get it, but you can't afford to buy it. And even the ones that can afford to buy it. They aren't near that BMI, [00:45:00] just want to look good. Nothing wrong with that. But we've got this two tier system again, 

DR JEREMY: Yeah 

VAL: It comes with how people look. You've got a group that can look good, be the size they would like but you, mere mortals. Can't have that there's a clear difference with how we are looking, 

DR JEREMY: It affects how you get treated. 

VAL: It does. Do 

DR JEREMY: Get a job?

VAL: I was watching this show the other day and someone was talking about that, that they were treated differently when they lost weight. 

DR JEREMY: Yeah. 

VAL: Know beautiful people get treated differently to people not in that beautiful box. I'll probably be in that box. Oh, I like how you didn't even say, oh, Val, you're not that ugly. I like that. 

DR JEREMY: No, I don't think of you as your obiest I was thinking I had a prior supervisor a very big [00:46:00] woman and we were having a conversation

DR JEREMY: She was talking about the way she gets treated as someone who's very obese. People would literally yell out to her as she walked down the street. In ways that would never occur to me. 

VAL: Yeah. 

DR JEREMY: She said guys in cars would drive by and yell, 

VAL: yeah, 

DR JEREMY: you're fat.

DR JEREMY: And she's I know. Or when she was walking into her GP office, the guy coming out ~her ~just said, you're fat and kept on walking.

DR JEREMY: Random comments. It's something people who are very obese have to live with.

VAL: Yeah. 

DR JEREMY: These little comments 

DR JEREMY: so it's no wonder , it affects mental health it was quite stunning to me, the way she got treated. 

VAL: They rolled down the window of their car and they shout

DR JEREMY: yeah. 

VAL: Yeah. 

VAL: It's awful. They do it all the time. 

DR JEREMY: Yeah.

VAL: Cause they think they can't look at that singer. What's the name? Who was all, for image positivity. You know that singer? Oh, you probably don't listen to music. Do you listen to music? 

DR JEREMY: [00:47:00] I listen to music.

VAL: What kind music do you listen to?

DR JEREMY: I listened to rock and roll. Jazz blues. 

VAL: Do you remember Lizzo? 

DR JEREMY: Lizzo. Okay. I know Lizzo. I've talked to people about 

VAL: Lizzo 

DR JEREMY: Body positivity. 

VAL: She has lost a lot of weight. 

DR JEREMY: How positive were her followers after that? 

VAL: I don't really follow, but I saw a picture of her online. Bloody hell. 

DR JEREMY: So why did she want to lose weight if she was about body positivity?

VAL: I don't know, how can I say this?

DR JEREMY: Did she get healthier?

VAL: Some people were going about, body positivity because can't lose weight. ~I don't ~and then, the potion arrives. Where people could, lose weight overnight without going to the gym, without lifting any weights. I don't know if she used it. Some people are saying that she did, but yeah, she's lost a lot of weight. Is she still into body [00:48:00] positivity? I don't know. 

VAL: It's accessible. 

DR JEREMY: If you can afford it, you get Ozympic. If you can't, you get body positivity. 

VAL: Let's talk about this., How are health inequalities measured? 

DR JEREMY: That's a good question. We often, talk about lifespan, like we've talked about in this episode, right? So measuring, how well things are, or we talk about mother infant mortality rates.

VAL (3): Yeah. 

DR JEREMY: Yeah. Yeah. , Obviously the incidence of certain kinds of diseases, 

but 

DR JEREMY: also the outcomes, how well they're treated or not. So there's various ways of measuring it. And I think just talking about all the complicated factors, I think the problem is it's not as simple as just saying, these are the groups in society.

DR JEREMY: Here's the proportion of the population and they're having a different outcome. So therefore inequality. It's really about, trying to look at the impact of these unfair, uncontrollable factors [00:49:00] that are influencing health and teasing it apart from all the other factors. 

Yeah. 

DR JEREMY: So it is a more complicated question than just looking at a single analysis.

VAL: So just that alone, do they tell the whole story? 

DR JEREMY: It depends on the stats you look at, so I think another thing, cause I used to teach research methods and statistics at a university. And I think one thing that we learned is like, when people are looking for a cause and effect relationship, we all like a simple main effect, right?

DR JEREMY: This thing causes that, right? 

DR JEREMY: If I water my flowers, they'll grow bigger. But oftentimes it's not a single factor. It's an interaction, right? So it's not like just the more water you put on your flowers, it always gets bigger.

VAL: Yeah. 

DR JEREMY: Because if there's not enough sunlight, 

VAL: exactly, the 

DR JEREMY: flowers aren't going to grow.

DR JEREMY: So what you actually need is, for the best impact you need, there's a main effect of sun and a main [00:50:00] effect of water. But if you have the two of them together, you get this exponential growth. And then if you add in other factors, really three factors, three interact like a kind of a two way or maybe a three way interaction, 

Yeah 

DR JEREMY: The maximum that a human brain.

DR JEREMY: Can comprehend right? So you can say like sun water in this case will make flowers get bigger. But in this case, you can have a different effect. You can almost understand one step beyond that, but it's pretty hard. And when we're talking about health, we're talking about really many, Factors.

DR JEREMY: And so the only way to look at it is to take the information we have about the different factors and try to hold them constant and say, if we isolate this variable, what's the impact of this, right? 

VAL: But then 

DR JEREMY: that just makes it easier to understand, but it isn't the whole picture, right? 

VAL: The human being, do you know what I don't mean? It's okay. It's like they say [00:51:00] when somebody goes in for an operation, okay. They occupy that bed for a few hours. Then they leave. We know somebody like my son has got sickle cell before he can have an operation. Does it need to be transfused? How long does he need to stay? Who else does he need to see? It's not just, in, bed, and out.

VAL: There are other things involved despite we have these stats, we are complicated. We are different. Individuals, which is why when they say things like in their reports, person centered NHS they can't even get the basics right. So if you can't get the basics right, how are you going to personalize something for each individual?

VAL: It doesn't make sense. Let's get some [00:52:00] things right. It's got to be social care, get the list of downs and social care will help drive down. People going into A& E, it will help that, but you've got to look at the deprived areas and resource them better.

VAL: If you don't resource them better, A& Es are going to be overflowing. We know winter isn't one of the, Oh my God, it's winter. It happens every year. 

DR JEREMY: Yeah, ~it ~

VAL: It's like Christmas. It shouldn't be a surprise. And we know each year the flu, it's different every year. We know people with certain illnesses the vulnerable, the young, the very old, we already know this. So why are we not already looking at certain areas that do have an influx of more people in winter? Why aren't we already looking at [00:53:00] those areas? I don't know if they are or they're not, but resourcing them better. If you've got to take a resource away from an affluent area that doesn't need it, but a deprived area does, they need it more.

VAL: It shouldn't be about. Okay, but we're in power. We're only going to look after the areas that voted for us. Whoever is in power should be looking after the UK, regardless of whether this area voted you in overwhelmingly, or this area doesn't.

VAL: Starving of resources. You don't need any more stats. And you don't need any more reports,

DR JEREMY: regardless, of which reports get written, I guess I would just come back to this idea of, do you want to make changes that. Benefit, the people who need it most bring people up to the same level or if there's an inequality, do you want to just put it in a, strive for, helping [00:54:00] the already healthy get healthier? I don't think so. You get more benefit from helping the people at the bottom. 

VAL: What normally happens after health inequalities report. 

DR JEREMY: Yeah, 

VAL: the health inequality widens. I don't know if that's the universe telling us anything. The whole story goes beyond just the stats. 

DR JEREMY: Yeah. 

VAL: You're talking about human lives. We talked about communities, young girls raised in children's homes. Thrown out at a certain age different communities, traveling communities, ethnic minorities, women, men, across the board. Life expectancy isn't too good. Between the deprived and the affluent, they say it's between seven to nine years. They say black women in the UK are three to four times more likely to die in childbirth than white women. I thought it was just giving birth, it's [00:55:00] a baby. It's a woman's body. My body is the same. Just a different color. Why should it be any different for me? It doesn't make sense to me as a woman who is going to give birth and another woman beside me. Who happens to be white. She's still a woman. We're both pregnant. We're both going in to give birth. Why should her experience be better than mine? Why is it I'm more likely to die? These are the things that create more inequality. 

DR JEREMY: Yeah. That's a really good question. And I think, if we want the answer, we need to look at all these factors and figure out. The unfair, controllable inequalities, the factors that contributed and that we can do something about. 

VAL: I'm getting depressed. Luckily I can't get pregnant anymore. It's horrible to read

DR JEREMY: Yeah. [00:56:00] 

VAL: Because when you see in part of the point, it black and white, it's 

DR JEREMY: Yeah. 

VAL: My first question is why, it doesn't make sense. I want to know, why these things happen ~in ~to correct them for the next generation. We're not going away. I'm not going to wake up white tomorrow.

DR JEREMY: So 

VAL: We know language barrier is an issue. We know cultural issues. Even though I'm born here, it doesn't say, as I'm reading the stats, it doesn't say it's because you're not born here. Yeah. But, I've heard stories of black women born here having loads of problems. You black women, you're built for pain. Some of those comments are made, you'll be fine. Or you just ignored, you hear of that, where I gave birth, I went home [00:57:00] so you can imagine I was the only black woman in the whole of the place.

DR JEREMY: Mhm. 

VAL: The nurse made a comment. Oh, we can't mix up your baby . 

DR JEREMY: Yeah. They won't give me the wrong

VAL: I wish they did. . I'm joking. No. I was too exhausted. To even give a damn. ~I ~the next question was. Do you want him with you? I was like, no, I've got the next 18 years. They're unlikely to mix him up. The only black baby born that year. I think, 

DR JEREMY: yes, 

VAL: honestly, I know he's 31. He's still living at home. That was the only thing said. 

DR JEREMY: Yeah.

VAL: She wasn't being horrible. . She wasn't being rude. It was a bit of a laugh, but I was too tired to laugh, I didn't take it anything. . 

DR JEREMY: Yeah. 

VAL: Health inequalities are about far more than personal choice. They're built into the structure of our society. To challenge them, we have to name them clearly [00:58:00] and often.

DR JEREMY: Absolutely. 

VAL: Okay. Let's do our stories, labels and misconceptions for this episode. If you had to summarize the story of inequality in one word or phrase, what would it be? 

DR JEREMY: Oh, you mean like inequality in health? I'm not sure. I think for this episode, the one phrase. It's deprived that's really the word

VAL: You learned today.

DR JEREMY: The word we came across, because ~I~ in the UK, at least seems to be driving inequality is deprivation.

VAL: For me, this episode is about exposure. The way inequality is hidden in plain sight. In systems that say they're fair, but we know it's not

DR JEREMY: Yeah. 

VAL: It's unfair.

DR JEREMY: It's unfair in subtle ways we don't often appreciate. 

VAL: Okay. So what's the label you think [00:59:00] society wrongly places on people who live with poor health outcomes? And I think you said something in the episode and I wonder if you're going to say it now. 

DR JEREMY: The label. I think we talked about people being you know, hard to reach, right? Or

DR JEREMY: That a label of kind of, I don't know, disengaged or

DR JEREMY: whether they're responsible for their own care or their own lack of health, right? Their fault. Yeah. 

VAL: Yeah. Yeah. The onus is on them. They're non compliant. 

VAL: So the misconception, what they got wrong. What is the biggest misconception about health inequality?

DR JEREMY: Probably that it's simple. It's not simple. It's complicated. So [01:00:00] yeah, I think we all, we're all tempted to think of it in a very simplistic way. 

DR JEREMY: We all imagine we could fix it, but I think the truth is it is just complicated. There's probably multiple solutions that all need to be, that will fix a part, but won't fix the whole thing.

DR JEREMY: So we do them all. And we all have a role. So there, there is a role for change and differences in the NHS or government funding, but there's also a role for other institutions in society and individuals too. And again, it's not because it's all their fault. But to be responsible is to have the ability to respond, right?

DR JEREMY: If you have the ability to respond, you're responsible. So I think it's going to take collective response. 

VAL: I think the biggest misconception we've challenged today is the idea that [01:01:00] everyone starts on the same page. We talked about that before, where you're born into, your outcomes, blah, blah, blah.

VAL: Or that the NHS alone can fix it. I think it takes a lot more than the NHS alone. It's going to it , as we said, it takes a village. 

DR JEREMY: Yeah. 

VAL: The NHS alone is not the village. It can provide us the resources. Things like that, but it's going to take a lot more than that. We, as the people, we as human beings, we have to be willing to comply.

DR JEREMY: Yes. 

VAL: To make our lives better. But we know that some people can't because they're in a place in their mindset where they're not able to. To get to the state where they are able to comply. Therefore, the NHS needs to provide [01:02:00] those resources to get everybody on that same page where we can all comply.

VAL: Yeah.

DR JEREMY: Thanks for listening. I 

VAL: enjoyed today because I do talking about health inequalities, but it is, it's complex.

VAL: It really is. When you think, one thing, something else pops up and it's it's not as easy as you think it is. So I'm going to learn Something along the way as well, so that's going to be good for me. 

Yeah. 

VAL: As we said in the beginning, this was part one of a series on health inequalities.

VAL: This was just about laying the groundwork. Next week is what Dr. Jeremy, would you like to say what we're talking about? 

DR JEREMY: So next episode, we're gonna be looking more carefully at social determinants of health. In, in particular the social determinants that affect health [01:03:00] inequalities.

VAL: Brilliant. Okay, now you can say it. The thing that you've been dying to say, you can follow us somewhere. You can say it and it's true. 

DR JEREMY: Yes. You can follow us on. Facebook, Instagram, Twitter,

VAL: that was the one. 

DR JEREMY: Although Twitter is now called X. 

VAL: Thank you for listening. We hope you enjoyed today. We've had a laugh. Okay. Some of the things we talk about are a bit depressing, 

VAL: i'm tired. See you next week. 

DR JEREMY: Okay. Take care Val. 

VAL: See you next week. I 

DR JEREMY: did. See you next week Val. 

VAL: Bye. 

DR JEREMY: Bye bye. 

You