Abstract
Globally, it is recognised that the fundamental causes of iniquitous health outcomes lie within unequal distributions of wealth and power. Internationally, however, policies and interventions persist in individualising the inequalities problem and targeting individual behaviours as the main solution. This approach has been argued to represent ‘Fantasy Paradigms’. This paper explores one example of such ‘Fantasy’ intervention from the perspective of health practitioners. Further, it explores opportunities for deepening practitioner understandings of the socio-political determination of health. Data were collected through in-depth interviews with 47 professionals involved in delivering a social prescribing programme in poor areas of Glasgow, Scotland. Data were analysed thematically across and within transcripts. Narratives highlighted different explanatory types concerning how the intervention could tackle health inequalities including: firm commitment to individualised approaches; hopeful pessimism; the social-determinants-of-health as an unpoliticised and nondeterministic backdrop to poor health; and finally, incomplete understanding of the social gradient as a population concept. Disrupted narratives of the social determination of health were also evident. This paper contributes new insights to existing debates on health inequalities discourse. These are conceptually important and identify opportunities for sharpening practitioner understanding of the social determinants of health which could in turn contribute to better, non-stigmatising primary care. It argues that re-engaging communities of practice with what is meant by determination of health is necessary and that there is a need to de-couple the policy aim of reducing health inequalities from the delivery of structurally competent and equality-focused public services.
Highlights
There have been calls to reframe thinking about the social determinants of health inequalities due to the gap between evidence and policy; the former focused on socio-economic circumstances, the latter on lifestyle behaviours1 (Elwell-Sutton et al, 2019; Phelan and Link, 2015)
The findings are drawn from data collected in the process evaluation of the Links Worker Programme (LWP) GPs and Community Links Practitioners (CLPs) were interviewed individually and in groups with a larger group of professionally qualified primary care staff including, for example, practice managers, practice nurses, and representatives from community organisations
Perspectives that acknowledge some role for socio-political factors in creating health and inequalities and that square this with the contribution of the LWP
Summary
There have been calls to reframe thinking about the social determinants of health inequalities due to the gap between evidence and policy; the former focused on socio-economic circumstances, the latter on lifestyle behaviours (Elwell-Sutton et al, 2019; Phelan and Link, 2015). Scott-Samuel and Smith, argue that policymakers who devise sub-macro level interventions to reduce health inequalities (HIs) are guilty of pursuing ‘fantasy paradigms’ (2015). This is a devastating critique for policymakers with commitment to social justice. Blinkered approaches to the evidence base concerning HIs causation lead to policy-making repertoires focused on responsibilisation and lifestyle change which merely nod to inequalities' socio-political backdrop. Even where this backdrop is acknowledged, the pervasive, health-damaging political context (in the form of decades-long neo-liberal policies and practices) ensures that more progressive policies swim against the tide. Scott-Samuel and Smith argue too that researchers collude in fantasy production through engaging in evaluation of such policies
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