The establishment of the NHS in the United Kingdom as a universal service for everyone, available according to need and free at the point of delivery, has been heralded as one of the great health achievements of the twentieth century. The NHS has enjoyed unparalleled public support, and its achievements in providing high quality care at relatively low cost are undeniable. There have, however, been some criticisms of this universalist model of provision. Whilst it appears equitable, in that the same service is available for all, in reality certain groups fare better than others. This has been evident in the debate around the ‘postcode lottery’ whereby certain geographical areas provide better services and manage to recruit and retain staff more easily than other more disadvantaged areas. In general, this reflects the socio-economic makeup of the local population, with poorer areas receiving poorer services. Many commentators have argued that the NHS perpetuates sexist, ageist and racist stereotypes and fails to adequately meet the needs of particular population groups (Doyal 1998). In order to meet the needs of specific marginalized, ‘harder to reach’ groups, targeting has been suggested as an appropriate strategy.

The scientific rationale rests on a notion of risk. Epidemiological evidence identifies these groups on the basis of their behavioural risk factors (see Chapter 11) or their health outcomes (ill health or premature death), access to care and services or in relation to particular characteristics such as low income, housing or work (see Chapter 9). For example:

Traditionally, analysis of modern society has seen it as divided by class, gender, sexuality and ethnicity and this social stratification as shaping experience and opportunities. Targeted population groups are normally those who share one of these characteristics and are deemed to have special health needs and include men/women, older people/children, homeless, teenage mothers, minority ethnic groups, and lesbian, gay, bisexual, transgender (LGBT) people.

A report by the Health Education Authority on the needs of the homeless provides a common argument for the explicit targeting of a population group: ‘due to the wide range of health-related problems that affect homeless people, and their particular living environment and lifestyle, interventions should be targeted to their specific needs, rather than relying only on those aimed at the general population’ (HEA 1999, p. 30). Blanket approaches simply cannot cater to everyone.

The term ‘vulnerable groups’ has been widely adopted to indicate those in need of particular provision. This could be because they have greater health needs; because their health needs are not being adequately addressed; or because they are at risk of social exclusion. Groups such as people with learning disabilities and looked after children might then be seen as vulnerable.

‘Social exclusion’ is a relatively new term used to describe groups of people who are marginalized and on the outside of society usually because of their lack of access to material and social resources and also because of their isolation from social interactions. The UK government has defined social exclusion as ‘what can happen when people or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime, bad health and family breakdown’ (Social Exclusion Unit, www.socialexclusionunit.gov.uk). Refugees and asylum seekers are an example of a group that is seriously threatened with problems of social exclusion. A disproportionate number of refugees become long-term unemployed, no matter what qualifications and experience of work they bring with them and most have problems of housing and community settlement.

Social exclusion, unlike poverty, includes several dimensions of deprivation and participation and draws attention to the ways in which people’s position in society may change over time (Hills et al 2002). It changes the focus of interventions from those to take people out of poverty or ameliorate its effects (see Chapters 5 and 9) to those that focus on involvement and engagement.

Targeting risk groups can seem an attractive proposition. Resources may be directed towards groups with the highest level of health needs, which should prove effective and equitable. As discussed in Foundations for Health Promotion (Naidoo and Wills 2009), needs assessment is intended to look at unmet needs for services and to provide information that will allow services to be tailored to local populations.

Target groups can be distinguished in two ways:

Within any target group such as older people (65 or more years of age) there are some people who have more needs than others, for example:

Targeting any group is thus problematic. Groups are often assumed to be homogenous for policy interventions when they may share important characteristics such as income or gender. Whilst this is important, behaviour is not simply a matter of following a social script, nor do individuals who share one characteristic such as their age necessarily form one homogenous group. For example, the experience of older women is very different to that of older men (Arber and Ginn 1999).

Understanding health disadvantage is often within a medical model that identifies physical health needs and barriers to accessing primary care services. Homeless people, for example, have marked health needs (see Box 12.4).

Being homeless also encompasses other aspects of health including isolation, insecurity and poverty, and one of the problems of targeting a population group is that these interconnecting needs that are pathways or barriers to health also need to be addressed. This requires partnership working across professional and organizational boundaries, so that social and health needs are met. It also means working with (rather than for) people as partners, listening to their views, and acknowledging their areas of expertise. For more discussion of issues relating to partnership working, see Chapter 7.

Carers are an example of a population group (estimated at 5.8 million in the United Kingdom) that has only recently been recognized as having specific health needs in common. The role of caring itself has meant that carers have been invisible in society and the National Carers’ Strategy (DH 1998) urges recognition of carers as individuals in their own right separate from those they care for and as a group with distinct needs (see Box 12.7):

Strengthening the community of carers may mean providing emotional support or help and advice from a support group. Mental and emotional well-being can also result from feeling in control of the situation – which means, for carers, having the information and resources to help them to care. Befrienders projects support isolated carers who have become inactive within the community due to their caring role. The role of the befriender is to provide company either in the carer’s home or on social outings and to offer support that is reliable, consistent and dependable. This example shows how a significant mental health issue may remain largely invisible unless a specific population group is targeted. By targeting carers, they are made part of the mainstream health agenda.

The example of HIV/AIDS illustrates some of the dilemmas associated with both targeting specific groups for health education and services, and adopting a universal approach. Gay men and intravenous drug users were the initial target of HIV health education messages in the early 1980s. Alongside some success of this approach in reducing the HIV infection rate amongst gay men were the negative effects such as the maintenance of heterosexuals’ illusion of invulnerability and a homophobic backlash. Predictions in the late 1980s of a heterosexual epidemic led to a change in emphasis and by 1990 the message was ‘it’s not who you are but what you do’, that is, targeting risk behaviours not risk groups. This was accompanied by a shift in funding from projects for men who have sex with men to professionally led initiatives aimed at the heterosexual population. Whilst this has meant more mainstream funding, the ‘de-gaying’ of HIV also led to a shift of attention from the group most at risk. The linking of HIV to broader sexual health issues (see Chapters 10 and 11) means that prevention funds are often used to support generic health promotion activities, needle exchange and sexual health promotion aimed at heterosexuals.

National patterns of HIV prevalence, however, and what is known of the existence of priority groups in local communities, would suggest that interventions targeting men who have sex with men, and African communities, should take precedence over interventions targeting groups who are easier to access but at much less risk of HIV such as ‘the general public’.

This chapter considers four different population groups – older people, children, Black, Asian and minority ethnic groups (BAMEG), and refugees and asylum seekers – in detail. For each population group, their specific health needs are outlined, followed by examples of different kinds of strategies and interventions targeted at the group to meet their needs.

The developed world talks of a demographic time bomb in the twenty-first century. The UK census of 2001 revealed that for the first time there are more people aged over 60 than there are under 16. People aged over 60 have risen from 16% of the whole of the population in 1951 to 19% in 2007. There are also 2.7 million people aged over 80. This poses major problems for the care and costs to the state of supporting an ageing population. Reducing mortality and increasing life expectancy is also not seen as an unmitigated public health success. The quality of life is also important. Although chronological age is not synonymous with disease and ill health, nevertheless there is an increase in frailty, chronic illness and greater use of health and social care services with increasing age.

Organizations such as Age Concern (Age Concern 1999) have consistently highlighted incidences of lower quality care and rationing of services based on age and not individual need. This has been of sufficient concern for the first standard of the National Service Framework for Older People (DH 1999) to be ‘Rooting out age discrimination’.

The health of older people does decline with age although there may be little association between chronology and physiological age. Degenerative conditions such as weaker muscles, loss of flexibility in joints, poor vision and hearing and loss of cognitive function may occur in the ‘young old’ of 60–70 or the ‘old old’ of 85 plus or not at all. Health problems tend to be related to a number of limited diseases for which the risk factors are well known – coronary heart disease (CHD) and stroke, cancers, respiratory illness and osteoporosis. Dementia affects 1 in 5 people over 85 although its severity varies. Although it is clear that as men and women reach very late life their activities become more circumscribed, in earlier late life their mobility and task capacity are unimpaired and they are well able to be involved beyond their home and household, in work, care giving, sport and recreations. A longer life does not necessarily mean worsening health. As people live longer, most morbidity gets compressed into the later years of life and many people reach ‘natural death’ without ill health. A review of health status in 1994 found it impossible to conclude whether the health status of the older population had improved, deteriorated or remained the same over the preceding decades of mortality decline (MRC 1994). Although health spending is higher for older age groups (40% of the NHS budget), the economic argument to prioritize older people because of their greater consumption of services and health needs is not the only or most convincing argument. An alternative argument is a rights-based one – to tackle age-based inequalities.

Standard 8 of the UK National Service Framework for Older People aims to ‘extend the healthy life expectancy of older people’. For most older people this means their independence, autonomy and maintaining their functional capacity. Yet disability as measured in relation to activities of daily life tends to rise in those over 70 and is mostly related to locomotor function. Nearly two-thirds of people aged over 65 cannot walk 200 yards without stopping or climb a flight of 12 stairs (DH 2007a). Falls and fractures are associated with high morbidity, mortality and substantial costs. In 1999, there were over 3000 deaths and over 85,000 serious injuries as a result of falls in older people (DH 2001). Hip fracture is the most common serious injury and this can precipitate admission to long-term care. Even those falls that do not result in injury may have psychological consequences of loss of confidence and fear (of a future fall), decreased activity, social isolation and depression.

Encouraging older people to remain physically active is a major priority. This means action in broader areas – ensuring the maintenance of pavements, better lighting in streets and parks, restricting traffic in residential and shopping areas, and improving town centres, as well as developing affordable and accessible public transport through concessionary fares and mobility buses and tackling community safety so that older people feel safe in public areas.