[00:00:00] You cannot afford to be sick. It's a luxury to take time off. You're less likely to see your GP. Likely to get worse. I think in health care, it's very easy to make the argument for health equity rather than, so much than equality.

INTRO: Stories,

INTRO: 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: Welcome to Stories Labels of [00:01:00] Misconceptions. Co hosted by Val Barrett. 

Dr Jeremy: I'm Dr. Jeremy Anderson. 

Val: We are continuing our health inequality series. Today is part three and episode one and two, what did we talk about? 

Dr Jeremy: in our first episode in the series, we talked about what health inequalities are and why they persist.

Dr Jeremy: Health inequality is really about the unfair and controllable factors that result in differences. in health between groups. And in episode two, we talked about specifically the social determinants of health, how things like that aren't health directly related, but things like housing, income, education, things that we don't normally think of as being related to health, actually contribute to health or ill health long before you reach a hospital.

Val: We're going to briefly just tell you about the 2010 Equality Act and the population groups commonly considered for health inequality. [00:02:00] These are the protected groups. 

Dr Jeremy: Okay. 

Val: So the protected characteristics are age, disability gender reassignment. marriage and civil partnership, pregnancy and maternity, race, religion, or belief, sex, sexual orientation. So those are the protected characteristics, right? Inclusion, health and vulnerable groups.

Val: Gypsy Roma travelers boater communities, people experiencing homelessness. Offenders, former offenders, and sex workers. Socioeconomic deprived population. Includes wider determinants. Like education, low income, occupation, unemployment, housing and geography.

Val: Population [00:03:00] composition, environment. Social connectedness and features of Pacific geographies, such as urban, rural, and coastal.

Dr Jeremy: So, the first nine characteristics from the Quality Act, it's illegal to discriminate on the basis of those things. 

Val: Yes. 

Dr Jeremy: It identifies specific vulnerable groups. 

Val: Yeah. 

Dr Jeremy: And then it talks about factors that contribute to disability vulnerability or unequal. 

Val: Yeah. Just like we discussed last week. 

Dr Jeremy: Okay. 

Val: Not all inequality looks the same. Some of the worst health outcomes in the UK are shaped by who you are, where you're from and what your body has been through. In today's episode, we ask who gets left behind and why.

Val: We'll look at health inequalities through the lens of race, disability, and class. This is more than statistics. It's about structural exclusion, lived [00:04:00] experience, and what needs to change. The first part is about race and equality. Dr. Jeremy.

SWOOSH: Mhm.

Val: we touched on it a bit. Last week or the week before about black women in childbirth. 

Dr Jeremy: Okay. Black women, three to four times more likely to die in childbirth. 

Val: Yeah. 

Dr Jeremy: There's a link between being black and more likely to die in childbirth, we're not saying there's a direct causal link. We're not saying the amount of melanin in your skin causes you to die. We're saying there's other factors related to those things that result in the connection. 

Val: Yeah. 

Dr Jeremy: So it's like we need to be detectives to try to figure out what are the factors that are related to, what are the factors that. Make this phenomenon, right? So what is it? I assume these statistics are from the UK. So [00:05:00] what about being a black woman in the UK that results in a higher rate of childbirth of death and childbirth compared to other groups? What are the things that contribute to death and childbirth?

Val: They're saying it's systemic bias, language barriers, and medical racism. As a black woman myself, who has given birth, I personally haven't experienced this. That's a personal, that's about me. Not to say that it doesn't happen. It does because the statistics are telling us that.

Dr Jeremy: Yeah, 

Val: We know that certain ethnic groups have higher rate of diabetes, high blood pressure, 

Dr Jeremy: Right? 

Val: Heart disease or lower cancer screening uptake.

Dr Jeremy: Yes. Specific populations of [00:06:00] people have different base rates. Of a particular illness or condition, that's not really a matter of bias. That's just the starting point, but when we talk about bias in the system, we're talking about a system that isn't perfectly attuned to the needs of the people in the system, or at least certain groups of people within the system.

Val: Certain groups, yeah.

Dr Jeremy: If you have a group of people that have a high rate of a particular condition, if the system isn't sensitive to that, or isn't meeting those needs there's a problem.

Val: They like to say that this group or certain groups, but let's stick with this group don't access services. But what if that service isn't accessible? To that person's needs. Yeah. Do you see what I mean? Because I myself have tried to access services. I know where they are. There's no language barrier for me yet. I've had problems. There always seems to be a barrier.

Dr Jeremy: What [00:07:00] is the barrier, just saying that it's black women don't access the system. 

Val: Yeah. 

Dr Jeremy: Why aren't people accessing the system? What creates a barrier to access? 

Val: I've always looked at this word access. And accessibility, when I read their reports, the onus is always on the person on that particular group. You haven't accessed us. So how can we provide a service to you? Or you're hard to reach because you're hiding. Which is ridiculous.

Val: I don't think it's as simple as that. We know there's a shortage of places, whether it's mental health, housing or whatever service it actually is. But when we come to pregnancy, we know at the end of that, you're going to have a baby. 

Dr Jeremy: Yes.

Val: So you've got to access something. Do you [00:08:00] know what I mean? You've got to be known by someone. So whether it's your GP, midwife, what else is there? Hospital appointments, clinics, there's always a stage throughout those nine months. How can you not be accessing? I remember 32 years ago, I didn't know I had sickle cell trait until well into my pregnancy, things can be missed, even in a borough where it was policy everyone got tested. My GP said, we don't know how you got missed. Some people do fall through the cracks, 

Dr Jeremy: Yeah, 

Val: I was visible. I was being seen. If I can fall through the cracks where a, [00:09:00] there's no language barrier I'm in communication with my GP and mid a midwife going to all my appointments. Why then does somebody like me still fall through the cracks? Because if that can happen to me, how are they supposed to reach out and provide a service to those that they see quote unquote, hard to reach, quote unquote, not accessing care.

Val: How is it that two women going in, both pregnant, same age.

Dr Jeremy:  Okay.

Val: So why is it that the black woman is four times more likely to die during childbirth than a white woman? Because that part, doesn't make sense to me. They're both [00:10:00] going in for the same thing to give birth. It is not exclusive to one group over another.

Dr Jeremy: Yeah. I don't think that number refers to all things being equal. Black women are three or four times more likely to die in childbirth. They're saying given factors are not equal, that's the number if you compare, two women one black, one not what might be a difference? Let's say one of those women, had a bunch of extended family and other kids, nieces, nephews, cousins to look after. Both pregnant, but one's got a bunch of other responsibilities makes it harder to attend appointments, for example.

Val: Okay.

Dr Jeremy: That could be one factor

Val: The outcome shouldn't determine that you leave alive. With your baby, I never went to mother and baby groups but I came out alive with my child. So wherever that person [00:11:00] lives, how they live, whatever health condition they have, doctors keep notes, it still shouldn't determine why that woman should die during childbirth.

Dr Jeremy:  Yeah, so Val, the numbers you've looked into do they talk about the cause of death when women die in childbirth? I don't know what people are dying from. Are they haemorrhaging bleeding? Or are they. having heart attacks what is it that actually is the cause of death? Did the numbers say anything about that?

Val: What are the 

Dr Jeremy: factors that preeclampsia.

Val: Preeclampsia. Blood pressure, which we mentioned because

Dr Jeremy: I can say a little bit about preeclampsia before working in sickle cell, I did volunteer work for a charity related to obesity. And one of the things that I did for them was I developed a training manual for midwives. [00:12:00] working with obese, pregnant women. And they talked a lot about preeclampsia. As a dude who's never given birth, I was maybe not the first choice for this. Role, but it did give me the opportunity to do a lot of research and learn preeclampsia refers to when an embryo doesn't fully implant into the uterus and a number of different effects on the way that the embryo or the fetus develops. It causes blood pressure spikes which can be dangerous or fatal to both the mother and the fetus. The child. There's a few different factors that increase risk of preeclampsia. One of them is obesity. So that the higher your body weight is, the more likely this is to happen. And I'm not sure if there is a higher risk of preeclampsia. In black women compared to women of other groups. But if that's the case, that's [00:13:00] one factor just as one of those base medical factors that could account for different outcomes. 

Val: Some say things like medical racism. I've never heard that before. 

Dr Jeremy: Yeah. I think you and I are both of a generation where like when someone talked about the word racism, what they were talking about generally was like overt racism, people who just said, I don't like that group of people because of the group they're in. That's overt, negative attitudes or behaviour towards groups of people. But, I think that kind of racism has attracted an enormous amount of stink.

Dr Jeremy: It really is just a reputational murder to accuse someone of that kind of racism. Over time, we recognise that's not the only kind of discrimination or negative impact of these types of [00:14:00] attitudes. They're more subtle so just that white pillar cases and burn crosses kind of racism, you know but over time, the structural inequalities are often referred to as racism.

Dr Jeremy: I know what they're getting at. In my view, I think we need a different word for it because when we talk about organisations being racist or medical systems being racist, you 

Val: Institutionalised, 

Dr Jeremy: institutionalised racism, right? There's people that this isn't what it means, but people are afraid. What this means is that the people in the institution are that kind of old timey. Pillow cases and burning crosses kind of racism and people freak out

Val: They're too dismissive.

Dr Jeremy: And so we spent an enormous amount of time trying to calm people down and say no, that's not what we mean. We're saying the system isn't aligned perfectly to different groups. 

Dr Jeremy: That's what we're saying,

Val: [00:15:00] for example, Louise, Casey wrote the report about the MET, all these things you wrote. They objected to the racism, it's amazing how people, we're not racist, but we ain't racist, she wrote that report and they will fight tooth and nail. That one word really gets off people's backs. 

Dr Jeremy: Exactly. And in some ways there's a good thing, right? Like people, if there's one thing people don't want to be, they don't want to be racist. Great. That's an improvement. That's a change from decades past.

Val: When a woman goes in to get better, she just wants what she's going to get. 

Dr Jeremy: Yeah. 

Val: She wants to be listened to. And heard. A lot of black women say they are not listened to and heard and not seen. Those are issues, 

Dr Jeremy: HMMM 

Val: The system itself, the NHS is supposed to be equal throughout. [00:16:00] Having a service that says, yes, we are going to provide equal care for all patients.

Val: I'm just saying providers, when faced with someone that doesn't look or sound like them, if we can provide a service That doesn't always dictate chapter and verse and say to clinicians that because of you and your system, this create barriers for such and such a group. What on the flip side, what does that do to the service providers?

Val: How does that make them feel that these reports are written about? The system can't work without people. People are the system. People make up the NHS and I believe everybody wants to provide the best care.[00:17:00] 

Dr Jeremy: Yes 

Val: wakes up one day and says, I want to be a nurse. I want to be on my feet, tired out 24 seven with very low pay. I don't believe that. But there's something outside of their control that's built. In the system to be unequal.

Dr Jeremy: And if we apply the same thing, say pregnant women, right? If there's a risk that black women have in pregnancy, That isn't recognised just because of a lack of familiarity. It's not a kind of racism on the part of the doctor. It's just a lack of familiarity. You're not recognising, Oh, these people are at a higher risk of whatever it is.

Val: We have an example of a story. 

Dr Jeremy: Yeah.

Val: It's about Nima, a black British woman in her early thirties. She was six months pregnant and went to A& E with sharp abdominal pain. She told the nurse she had [00:18:00] complications before and was worried it could be early labour.

Val: The staff dismissed her concerns, saying it was likely just anxiety. Hours later, she went into premature labor alone in pain still waiting to be seen amina survived, but her baby didn't. She later found out black women in the UK are almost four times more likely to die in childbirth than white women.

Val: According to MB. Embrace dash UK, and these are figures for 2023, the maternal mortality for black women is, as we said, 27. 8 deaths per 100, 000 compared to 6. 6 for white women. Reasons include, as they said, [00:19:00] medical racism, lack of listening to patients' concerns, And inadequate care pathways.

Val: So Mia's story isn't about fear is about routinely being unheard in a system that wasn't built for her voice. So I know from watching this pro this program that many women feel like that. Yes, many do. And to flip the coin, some white women also feel that way. The figures of. Dying in child are more dominantly for black women, but we know that class can also play a role when it comes to white women.

Val: Okay. Let's move on to. [00:20:00] Disability.

SWOOSH: Mhm.

Dr Jeremy: We're talking about different kinds of disability. Something close to my heart given my occupation is the level of mental health services in this country just to take the most stark example is, someone with schizophrenia who suffers from delusions and hallucinations. They're floridly psychotic. That person is disabled. They're not able to think properly. And they're not able to function. So that would clearly be a, 

Val: A source of disability. 

Dr Jeremy: Yeah.

Val: I know Dr. Jeremy, there are so many different types of disabilities, but for this episode, this section, we're just going to focus on people in wheelchairs because people don't seem to think about wheelchairs. Accessibility.

Dr Jeremy: I can think of a woman we'll call her. Rene. She [00:21:00] was an elderly woman who had mobility problems, used a wheelchair.

Dr Jeremy: But so she couldn't go up and down stairs, but lived on the fourth floor of a high rise as a result. She was housebound. She often couldn't attend her appointments. If she did need to leave her flat, she had to basically call an ambulance or firefighters to carry her because the lift wasn't working.

Dr Jeremy: If someone can't leave their building. They're probably not going to attend health care appointments, even if they attended people in wheelchairs need access to the tube some tube stations have lifts.

Dr Jeremy: But not all tube stations have lifts. They're supposed to, but they're, but it's not going to happen for decades because 

Val: These tube stations are very old.

Dr Jeremy: Yes. The way the law is implemented where, they have to have lifts is they install the lifts when they're going to renovate the station.

Dr Jeremy: They have to. Yeah, install lifts. [00:22:00] But many stations they haven't renovated yet. Don't have lifts so some stations have them. Some don't, 

Dr Jeremy: so you have someone who it's difficult to get out of their building. Travel around their city.

Dr Jeremy: And once they arrive at their NHS, GP clinic or hospital, those buildings may also be very old. May not be. Wheelchair accessible. Disabled adults in the UK are twice as likely to report bad or very bad health compared to non disabled people.

Dr Jeremy: That comes from the difficulty they face trying to, stay healthy, improve their health and keep it. They can face longer waiting times or more cancelled appointments. If they're not able to attend an appointment on a given day because of a disability, that has to get rescheduled.

Dr Jeremy: They have a longer wait for services and it means that when they do get diagnosed with things like cancer or other things they tend, they get diagnosed late with the later you catch it, the worse the outcome

Val: Yeah.

Dr Jeremy: One [00:23:00] problem with working remotely. So I see a lot of patients virtually remotely. And so that, that actually can really help with people with mobility problems, because if they can stay at home, they can have a session where they see someone, but by video, but if that's not the only source of disability, if if you have a visual impairment using audio visual media, like a video call, isn't an option if you communicate by Braille a video call isn't an option. The more disabilities you have. 

Val: A freedom of information request revealed only 35 per cent of NHS trusts fully comply with the accessible information standard, meaning a large majority of failing to fully implement it. This standard ensures accessible communication support for people with disabilities or communication needs. 

Dr Jeremy: That's a good example of, we can pass the law or set the standard, but that doesn't necessarily mean institutions are going to meet the [00:24:00] standard.

Val: We know that some are not worth the paper they're written on. 

Dr Jeremy: Yeah. 

Val: Some think just by having a bigger toilet, it's wheelchair accessible. There's nowhere to change anyone. If somebody's wearing a, what's it called? A colostomy bag, all of those things.

Val: They just think just by providing a bigger space, that is it. It's a bit more than that. Do they have disabled people helping them design these things? That's the thing. Or do they just go back? Oh, we've just got that space there for a baby. Disabled loos I'm not really just about changing a baby. Do you see what I mean? 

Dr Jeremy: Exactly. That is the changing face of healthcare where a lot of conditions that used to be fatal. Are now chronic, they're [00:25:00] managed. But it means people have specific needs, like colostomy bags or peritoneal dialysis, it means people are carrying a lot of stuff and need access to non-standard toiling facilities. 

Val: Not all clinics are wheelchair accessible, some hospitals, are very old and haven't been refurbished. So imagine you are wheelchair bound and you have an appointment, they sent you to a specialist clinic, but there's no wheelchair access. 

Dr Jeremy: Yes. 

Val: You can't make that appointment, because all these letters are given up their standard. Your appointment is at blah, blah, blah. Is it considered for people that are blind in wheelchairs? With learning disabilities,

Dr Jeremy: [00:26:00] Yes, that's another thing that isn't appreciated is, people with learning disabilities or specific cognitive deficits that maybe they didn't have before, but they develop over time sometimes, in dramatic fashion is in the case of a stroke, but even if they haven't had a specific acute event, there, there can be a gradual decline or subtle damage over many years so that people who were, had some capability before are gradually losing that capability. And if it's not detected, then what happens is we're trying to interact with people in the same way as before. But they're not responding as well. We don't know why and probably just blaming them. And what really needs to happen, is, that we recognise that a deficit has arisen and and we need to provide people information in a different way. 

Val: Yeah. You provide the information, but also have the [00:27:00] facility. And the resources that person needs once they get to their appointment, 

Dr Jeremy: Yes 

Val: How are they going to get there? Do they have a carer? Support to bring them in? Are they fully aware of what's going to take place, it could be a woman who's going to have, A smear test, or she's got ovarian cancer or whatever, does she understand what's going to happen?

Val: Do you see what I mean? Yeah. Because we've got to remember these clinicians, they're specialising in what they do. They may not be specialised in working with people with learning disabilities. 

Dr Jeremy: Yeah. 

Val: Working with the deaf. Working with the blind. They need those resources on site when needed. 

Dr Jeremy: Yeah. 

Val: Do you see what I mean? This group can have a better health outcome because we know the outcome for this group is low. They're [00:28:00] less likely to speak up. They're sitting in A& E, they're less likely to shout out, like some people will scream out. So sometimes when you're sitting there quiet, you are left behind.

Val: We know they face longer waiting times. A third of NHS, yeah, , we stated that, but yeah, there were all the protected groups don't seem to be protected. They're all vulnerable, each and every one of them. And you'd think when somebody comes in especially somewhere as busy as A& E, right?

Val: Yeah. Clinicians need to think differently. It's hard. A and e. Is so fast paced. People with mental health. Breakdowns. I've seen it. People [00:29:00] running after them. It's mayhem. It really is. I think people have to be more aware of these groups, people would disagree, but I myself as a carer, I advocate for my child, but I , I'm not around, I would want him to be seen and heard. 

Val: Okay. So the example story. There's a man named Tom.

Val: He's in his fifties, and he has a physical disability and he uses a wheelchair. He needed urgent follow up after a cancer diagnosis. The hospital booked him into a clinic that wasn't check accessible when he asked for a virtual or alternative appointment. He was told to [00:30:00] wait another six weeks. By the time he was seen, the cancer had spread.

Val: He told me, I didn't feel like a priority, just a problem no one knew how to solve. Sadly, that feeling reflects the bigger picture. Disabled adults in the UK are twice as likely to report bad or very bad health. Compared to non disabled people, that is from the ONS 2022, they also face longer waiting times and more cancelled appointments, especially for mental health and diagnostic services.

Val: And it says over 40 per cent of NHS services still fail to meet basic accessibility standards. So Tom's story [00:31:00] shows that when the system isn't physically or digitally accessible, people fall through the cracks or are left waiting while their health declines. 

Dr Jeremy: And I think when people have multiple health conditions or sources of disabilit,y this often goes hand in hand with poverty or lower socioeconomic status so maybe this is a good time to segue into. Section three.

Val: Class and poverty.

SWOOSH: Mhm.

Dr Jeremy: What do we mean by class? 

Val: I want this to show how income and postcode define health outcomes. 

Dr Jeremy: Right. 

Val: Living in a certain postcode, you'll have better resources.

Dr Jeremy: Yes. 

Val: I live in the city, I live in SW 10 and where [00:32:00] I am, I have five. Major hospitals, three, within been walking distance two, I can drive to. 

Dr Jeremy: Yes. 

Val: One of them is a cancer specialist, the Royal Marsden. Then we've got the Royal Brompton. I went there for my lungs. Then you've got Chelsea and Westminster, and they're all on the same road. 

Dr Jeremy: Yes. 

Val: Then the other side of me, I've got Hammersmith, which is a designated heart attack unit. I went there when I was ill with my heart. And then up the road, we've got Charing Cross. So I'm in a prime position to get good health. When you hear stories of people having heart attacks and they're lying on [00:33:00] trolleys. My experience was, when I was having mine, my son dialed 999, paramedics came, examined me, they knew what it was, they called ahead, they were waiting for me at the door. Went straight to work. No waiting, no queuing, 

Dr Jeremy: I was going to say, so that is one of the factors that contribute to lower mortality or longer lifespan in more, affluent areas that have those services nearby. Means when something happens. Emergency services come there is emergency service in the area 

Val: Yeah 

Dr Jeremy: it doesn't take long to get there.

Val: Exactly.

Dr Jeremy: What are the other factors? 

Val: Chronic illness starts earlier in low income communities. 

Dr Jeremy: What we've talked about before with the different factors that contribute to chronic illness including environmental exposures, occupation, stress [00:34:00] housing, lack of adequate nutrition, combined over the lifespan to contribute to chronic illness.

Dr Jeremy: If exposed to more factors chronic illness starts earlier. If you develop chronic illness. And health care services are not available you have poorer outcomes than people in other areas. 

Val: But also when you're living in a house that's what damp and mold. 

Dr Jeremy: Yeah. 

Val: Have a young child. They can . What's it called? Respiratory. 

Dr Jeremy: yeah, there's a number of respiratory conditions people can develop. 

Val: And also people's jobs. 

Dr Jeremy: Yeah. If you work a job where you don't have as good a benefits or if you're not working, you don't get paid well, how often do you take time off to go to the GP or appointments or get an investigation done?

Val: Yes 

Dr Jeremy: By the time people catch an illness, it's later 

Val: Yeah 

Dr Jeremy: that tends to be more severe. 

Val: Yes.

Dr Jeremy: You don't have as good [00:35:00] an outcome. 

Val: We know resources, housing, work, unemployment low income, asthma, people with asthma, on a low income and they're just over that threshold where they can't get free prescriptions.

Dr Jeremy: Now They to pay.

Val: They have to pay. Yeah. Now, if you have X amount of children and you got all the essentials to pay for, we know the cost of living is higher. . We know that through the studies that Asthma UK have done. is that they are less likely to get their prescription. Therefore, their asthma gets worse, they're likely to end up in A& E.

Dr Jeremy: Correct.

Val: So we talked about cause and effect before. So even though the government cutting costs at one end, [00:36:00] and they think they're saving costs at another it's down the road, it's moving it somewhere else.

Val: Yeah. If you're cutting in housing education or social care. And that impacts on families, that cost will go to the other part of social care, but then if social care is being cut because they don't have the workers, they don't have the staff because they said they want to cut the amount of immigrants coming in to do social work, then that cost then moves to the NHS.

Val: All it does is it moves along. It's all it does. 

Dr Jeremy: It's not solved with 

Val: Anything. 

Dr Jeremy: No, it's not a real solution; the solution is to make people healthier, to reduce those costs.

Val: But in some cases we're making people [00:37:00] sicker, when you're working class, you can't afford to be sick.

Val: If you're on zero hours contract. You cannot afford to be sick. It's a luxury to take time off you're less likely, to see your GP. Likely to get worse,

Val: and until you're at that stage where you really can't do anything, Then you'll go to A& E, and some cases, as we know, people get diagnosed late, whether it's cancer or heart disease, 

Dr Jeremy: Yeah. 

Val: So we know that structural neglect, underfunded GPs, longer waits and fewer options. No options when you live in a certain postcode, you don't have any options. I'm not in that income bracket where I can go private. 

Dr Jeremy: No, 

Val: but I do get better health care [00:38:00] because of where I live, not because of what I earn or what I do. Do you see what I mean? So if they already know. Their data, their statistics are already stating that if you live, in a deprived area,

Val: people are less likely to live beyond a certain age, more likely to be unemployed, more likely to be on disability. So wouldn't you think that's where the resources need to be concentrated, not taken away, not left behind every time there's a new government, they say, we need to level up the North because it's always been left behind.

Dr Jeremy: Yes. 

Val: And these communities where there's poor housing, there's poor housing in the South as well. But when you have poor housing, poor resources, high [00:39:00] unemployment, high amount of people having to claim disability. That would be the area where they really do need to plow, not just, it's not just money because let's say there is loads of money is where you distribute. Money. Money. Do you see what, do you see what I mean? Yes. Is that money going to the correct places? 

Dr Jeremy: Yeah. So a concrete example of that would be the current debate with the winter fuel payments.

Val: Yeah. 

Dr Jeremy: So older people get winter fuel payments but some of the older people in society are some of the wealthiest if you're a millionaire, do you need the winter fuel payment? Probably not. You can probably afford to put the heat on.

Val: Yeah. But when we means test benefits, there's a cost sometimes that cost doesn't justify the overall, what am I trying to say? 

Dr Jeremy: You wouldn't want a system that, [00:40:00] costs more to implement than it saves.

Dr Jeremy: If it's cheaper to give everyone the same amount fine. But if you could direct funds to where they're needed where people who don't need it, don't get it, but the people who aren't getting it, but need it, start to get it, obviously we're in favor of something like that.

Val: Is it always fair to beat the wealthy? They made something of their lives. Not all were born with a silver spoon. 

Dr Jeremy: No, 

Val: they've come good. They've made money. A lot of them give to charity. Do a lot of good things.

Dr Jeremy: Yeah. 

Val: Being fair with the tax system. Because when you cut from the bottom, that only helps the ones at the top.

Dr Jeremy: Yeah. I'm agnostic as to how we would want to do this. I'm not an economist. If you wanted to do it through a progressive tax system I have no problem with that. These are political decisions, what kind of society do we want to live in? Do we want a society where everyone gets, taxed [00:41:00] or receives the same benefits equally? Or do we want to direct things where they're needed more? That's the difference between. Words like equality and equity, those are not synonyms.

Dr Jeremy: They mean different things. Equality means that we actually treat everybody equally. And equity means, there's various ways of describing it. And some people that the online debate. I think people are down on equity. It seems unfair. Like if somebody is getting something, I must be losing, but really, I'm not saying I think that I'm saying that the people who are down on equity would argue, they would say, I don't like it that you're getting something that I'm not getting.

Dr Jeremy: Cause I feel like I'm losing. But it's, not actually, that's not really it. There really are people out there who have needs that I don't have. 

Val: Yeah.

Dr Jeremy: So if those needs get met, it is making up for a hardship i'm not losing. In fact, 

Val: you're gaining. It means society [00:42:00] gains, if people at the bottom are brought up 

Dr Jeremy: yeah. 

Val: When people at the bottom get worse, it's a bigger cost. 

Dr Jeremy: Absolutely. I think they 

Val: may think they're saving today. But it's going to cost more tomorrow.

Dr Jeremy: And I think in healthcare, it's very easy to make the argument for health equity rather than than so much than equality, or at least equity in terms of where we direct the resources. We want to direct resources, we give people medication who need it. We don't just dole out the same medications to everybody, right? It's based on need. It's always been based on.

Val: Yeah. 

Dr Jeremy: In other areas. Maybe the job market or other things, there's maybe a different philosophical argument. Does it make sense to say that, everybody wants to be, I don't know, an architect gets to be an architect, no matter how good at math they are or aren't?

Dr Jeremy: We ain't good at math. 

Dr Jeremy: I'm not the best at math not a good engineer. If I wanted to be one, spending effort making me into an architect, [00:43:00] probably not worth it. 

Val: We can always say, I want to look at football. For example, you have these youth academies, right? 

Dr Jeremy: Yes. 

Val: All these young men and young girls going through it, but how many make it a very small percentage? 

Dr Jeremy: I think sports is a great example, right? It's not an equity based endeavor, we're really interested in who is the best at this thing. 

Val: Yeah. 

Dr Jeremy: That's all we want to see. As a spectator, you want to see the best people on earth doing that sport. 

Val: But when you look at football and the majority of the players, they come from working class families.

Dr Jeremy: Yeah. Yeah. Yeah.

Val: And then once they get to a certain level and earning a lot of money, they're moving their family out of poverty, lifespan in football, isn't long.

Val: How easy is it for someone unemployed for a long [00:44:00] time to get on the employment ladder? It's hard. When they say, go and get a job. It's not as easy as they believe I remember years ago, I applied for this job.

Val: It was working at GPS. Over a thousand people applied for two roles. 

Dr Jeremy: Yes. Exactly. 

Val: No one's going to read them,

Dr Jeremy: I think that's only going to get worse the workforce going forward is just going to be more difficult for people to have gainful employment.

Val: There are gaps, social care, always looking for nurses, but social care is where the gap's going to be. So perhaps the government need to do more, make it more attractive, whether it's the hours, pay, career progression but it's got to look more attractive people to want to do.

Dr Jeremy: I think we just have to increase to make that an occupation people want to get into. It has to [00:45:00] be built up in terms of status. It should be recognized as a high profile occupation. It's an important job. We really do need it. 

Val: Yeah. 

Dr Jeremy: Whether we like it or not.

Val: It's going to get bigger. 

Dr Jeremy: We're getting older. Demand is growing. You might need care. 

Val: Yeah, absolutely. I might need care. The thing is, in Scotland and Wales, they have that. Register. Where people have to. So it's seen more as a profession. England has to go that way. They have to see it as a skill job and value the people that work in social care. 

Dr Jeremy: Yeah. So if we value it, we respect it, it's high status.

Dr Jeremy: Well compensated, I think that will solve the problem. These jobs are very difficult to fill because we don't value them. If we made our pay scales a little flatter higher earners don't need to make so much more.

Dr Jeremy: And the people who are not making much could make a bit more. That would make a stronger society. I don't see why CEOs need to [00:46:00] make a bazillion pounds, right? They can make somewhat more, but they don't have to make so much more 

Val: bonuses.

Dr Jeremy: Are you familiar with Ben and Jerry's ice cream? 

Val: Yes. 

Dr Jeremy: Did you know how salaries were connected how the salaries work in that company? 

Val: No. 

Dr Jeremy: They set a cap on the difference between the highest and the lowest paid person in the company.

Val: Okay. 

Dr Jeremy: And I, I don't know exactly what the limit is, but it's something like, the CEO, can only make, I don't know, 70 percent more than the lowest paid person in the company. There is a hierarchy. People do make more money as they progress. 

Val: There's always going to be a hierarchy.

Dr Jeremy: There's always some hierarchy, but it's flatter, right? Yes. So what it means is, the person sweeping the floors or doing the lowest level job. 

Val: Yeah. 

Dr Jeremy: Is making a really good wage compared 

Val: really Ben and Jerry's. 

Dr Jeremy: Yeah as the company does well, everyone 

Val: does well, 

Dr Jeremy: Everyone moves up, a rising tide floats all boats. [00:47:00] Capping the salary of the higher paid people, leaving more money for the lower paid people means everyone comes along as the company prospers. I think something like that, in society.

Dr Jeremy: Would be helpful in addressing a lot of problems we're talking about. 

Val: We can't do anything about class because we don't have a classless society. Poverty. The root out of poverty is work. 

Dr Jeremy: Yeah. 

Val: So the government need to support those that work. Want to work, have a better wage

Dr Jeremy: I recently came across a program called work well. They meet with people initially to determine what benefits they're on, what they could be on and making sure that as they pursue a work opportunity, it doesn't make them worse off.

Val: An example, story of class and poverty. it's too poor to be sick. The cost of care in a working class life. [00:48:00] Let me tell you about Darren, a delivery driver from a council estate in Sheffield. He's in his late forties, has diabetes and early signs of heart disease, but rarely sees his GP Why? Every time he takes time off for a checkup, he loses income and is already struggling to cover rent. heating and food for his kids. Last winter, Darren collapsed at work. His blood pressure was dangerously high. When asked why he didn't come in sooner, he said, I knew something was wrong, but I can't afford to be ill. If I stop working, everything stops. So his experiences, it's backed up by data. Men in the most deprived areas of England live 9. 7 years less than the least deprived. For [00:49:00] women, it's 7. 9 years less. People in low income areas experience chronic illnesses. 10 to 15 years earlier, especially heart disease, diabetes, and COPD, and many avoid care altogether. Over 30 percent of working class adults delay appointments due to work or travel costs.

Dr Jeremy: So 

Val: Darren's health wasn't just shaped by genetics, it was shaped by postcode. Income, and an impossible choice between getting and getting by. 

Dr Jeremy: Exactly. Perfect. 

Val: Yeah. I'm sure there are many Darren's. 

Dr Jeremy: That perfectly encapsulates what we've been talking about in this episode people's situation, where they live, the opportunities they have or don't have, all work together to result in [00:50:00] an outcome. I think that's a perfect example.

Val: Hey, Dr. Jeremy. We've come to the end at last to this grueling episode. 

Dr Jeremy: Yeah. 

Val: Finish off.

Dr Jeremy: Okay. 

Val: With our labels and misconceptions. We've had our stories. 

Dr Jeremy: Yep. 

Val: Give me a label misconception, please. 

Dr Jeremy: The label and misconception I wanted to talk about was again, this idea of equity. Versus equality, I think a lot of people are confused about what equity means.

Dr Jeremy: Some people think it means unfairness, like somebody's getting something I'm not getting, but that's really not true. Equity is really about safeguarding the people who need it the most. 

Val: Is that your label? 

Dr Jeremy: The label would be, yeah, equity and the misconception is that it's, it means unfair giving more to one person versus another.

Val: [00:51:00] Okay. 

Dr Jeremy: And I think that's a misconception. I think it really is about safeguarding the people who need it most to get equality of outcome sometimes equality of opportunity sounds great. And what about you, Val? What's the label you want to talk about in misconceptions?

Val: I'm going to use it again my label is hard to reach. So we look at the three stories, we look at the people of colour, disabled people, working class families that often labeled hard to reach. No, one's hiding.

Val: They're not hard to reach. What might be hard to reach is accessing your services if they've got to catch a train and a plane to get there, to be seen that's hard. Resources need to be accessible. 

Dr Jeremy: Yes. 

Val: My misconception is, that the NHS treats everyone equally. I think they do [00:52:00] in a sense, but, 

Dr Jeremy: We're seeing unequal outcomes, 

Val: the outcomes say differently. 

Dr Jeremy: People have different opportunities.

Val: We can't disagree with the outcomes. So when you present that, you say, wow, we're not all treated the same or outcomes are different.

Dr Jeremy: Yeah. 

Val: Okay. That's it

Dr Jeremy: Okay.

Val: Thanks

Dr Jeremy: Have a great weekend.

Val: Finished. 

Dr Jeremy: Yeah. 

Val: Okay. 

Dr Jeremy: Okay. 

Val: Rushing me now. After about two hours of episodes. I know. 

Dr Jeremy: You've inspired me to check out Planes, Trains and Automobiles. I haven't watched that film for years. 

Val: Thanks. John Candy. 

Dr Jeremy: Those aren't pillows.

WOOSH: Mhm.

Val: The most marginalized often carry the heaviest health burdens, not by chance, but by design. Next week we ask if we know the [00:53:00] causes and have the data. Why aren't things getting better? Thanks for joining us for episode three of our six part series on health inequalities. 

Val: We hope you'll join us goodbye from me Val Barrett 

Dr Jeremy: Dr. Jeremy Henderson. 

Val: Goodbye. 

Dr Jeremy: Thanks. Bye 

Val: link us on our socials and share us.

Val: Yeah. We're on Twitter, Instagram and Facebook. 

Dr Jeremy: We're everywhere. 

Val: For now. 

Dr Jeremy: Bye.

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