It is one of the key concepts to have come out of the Marmot Review. If you are not familiar with this review then, well, why not? It is a comprehensive and thoroughly well researched statement of what causes health inequality and what we have to do if we want to reduce it.
The report that came out of the review, Fair Society, Healthy Lives, argues that inequalities in health cannot be tackled effectively if we only focus on the most deprived:
To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism. Greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient, and will only tackle a small part of the problem.Here are a couple of charts which seek to illustrate the point (I have borrowed them from a presentation by Dr Fu-Meng Khaw that can be found here):
Instead of thinking about equality of service output, as local government has traditionally done, we need to be thinking about equality of service outcome. Even more than this, remember that services are already universally in-proportionate by virtue of the fact that the middle classes are able to draw down public services more effectively than those lower in the social scale. This research by Matthews and Hastings is a really interesting exploration of exactly that issue.
As Llaria Geddes points out in her presentation to the Greenwich Health and Wellbeing Partnership (that can be found here), practitioners and professionals get proportionate universalism as a concept but find it less easy to understand how it can be put into practice.
Using some of the examples in that presentation I want to offer some tentative suggestions about how proportionate universalism might be applied in practice. In part this is about breaking down services into types according to the way that they are delivered.
1. Invest in Services that are Intrinsically Proportionate
As Llara Geddes notes in her presentation, some services have proportionalism built in. Some services, such as GP services for example, are tailored to individuals and should automatically respond to levels of need. Other services, such as the provision of green spaces in urban areas, can be more attractive for those who need them most and will have less of an impact on people with the resources to travel or to live in greener areas.
2. Specify Service Zones
For ‘place based’ services such as street cleansing, street lighting and planning, outcomes can be ‘equalised’ by concentrating services at different levels in different areas. ‘Service zones’ would work just like planning or environmental areas, conferring a particular status on a geographic area with maybe three or four levels. For street cleansing this might mean having different frequencies of service depending on the level of risk for an area. For other services it might mean different speeds of response times for repairs or dealing with graffiti etc. For planning it might mean more intense advice or consultation in areas less likely to have the resources to engage with planning processes.
3. Build the Right Referral Systems
For services that are provided directly to households or to individuals (e.g. benefits advice, pest control and home energy advice) referrals can be used to ensure that access is increased amongst those less likely to ask for services or respond to advertising or marketing campaigns (it may be better not to do these at all). Referrals can take place across any services but ‘first line’ services such as GPs and health visitors will be particularly important.
4. Provide Enhanced Services
The presentation gives the example of the fire service giving additional support for vulnerable people. In the same way any service provided directly to households / individuals can include triggers for extra layers of service.
5. Carefully Target Population Groups
Providing services to certain population groups will have a proportionate affect because of the nature of those groups. The presentation gives the examples of providing effective contact to, and support for, young people who are not in employment, education or employment. Carers and care leavers are other examples of these types of group.
6. Ensure that Service Centres are Community Sensitive
Many services are delivered via physical centres - in other words from a building within a community. Examples include health centres, schools, libraries, leisure centres and community centres. The way that these centres provide their services can be varied, whether in terms of opening hours, access, associated groups (PTAs, friends of), community involvement or facilities. A proportionate approach would ensure that centres are sensitive to the needs of the community where they are located and that their services are adjusted accordingly. They can also provide an excellent point of referral for other services.
7. Provide New Service Centres
It might be that existing service centres are not enough to ensure that access is being ‘equalised’. Sure Start centres are an example of an initiative that concentrates universal services. The spatial distribution of these types of centre can ensure a proportionate approach.