Addressing health inequalities in England: Implementing policies across central government

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Addressing health inequalities in England
Implementing policies across central government

• Don Nutbeam
• Head of Public Health
• Department of Health

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Acheson Inquiry Key headlines

• Overall progress in health has not improved the
  gap in health status between rich and poor
• Although average mortality has fallen over the
  past 50 years, unacceptable inequalities in
  health persist. For many measures of health
  inequalities have either remained the same or
  have widened in recent decades.
• Inequalities can be observed throughout the
  lifespan
• These inequalities affect the whole of society
  and they can be identified at all stages of the
  life course from pregnancy to old age..
• Inequalities can be observed across a range of
  social indicators
• Inequalities by socioeconomic group, ethnic group
  and gender can be demonstrated across a wide
  range of measures of health and the determinants
  of health.
• Independent Inquiry into Inequalities in Health,
  1998 (www.official-documents.co.uk/document/doh/ih
  /contents/htm)

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The Acheson Inquiry ReportKey Recommendations
on actions required to address health inequalities

• All policies likely to have an impact on health
  should be evaluated.
• Families with children should be a priority.
• Reduce income inequalities and improve the living
  standards of poor households
• Major gains will be derived from those health
  problems which occur most frequently
• Policies which improve average health may have no
  impact on inequalities

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Tackling health inequalities policy context

• Saving Lives - Our Healthier Nation (1999)
  establishes public health policy for England,
  overtly cross-government, supports partnership
  between individuals, communities and government
  (www.doh.gov.uk.ohn.htm)
• The NHS Plan commitments (July 2000) bringing
  substantial new investment for a modernised NHS,
  chapter on Health Inequalities focussed on public
  health interventions, access to services and
  distribution of benefit of new investment.
  (www.doh.gov.uk/nhsplan)
• Announcement of two national health inequalities
  targets (February 2001)

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Targets to reduce health inequalities

• National health inequalities targets
• Starting with children under one year, by 2010 to
  reduce by at least 10 per cent the gap in
  mortality between manual groups and the
  population as a whole.
• Starting with Health Authorities, by 2010 to
  reduce by at least 10 per cent the gap between
  the fifth of areas with the lowest life
  expectancy at birth and the population as a
  whole.
• Simplified in new DoH Public Service Agreement
  as
• By 2010 reduce inequalities in health outcomes by
  10 as measured by infant mortality and life
  expectancy at birth

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Much action has been taken and resources released
(albeit not always joined up)

• Tax and welfare reform to reduce poverty
• National Service Frameworks intended to level
  up health service access and quality
• Health Action Zones direct resources to
  partnership working in disadvantaged communities
• Neighbourhood renewal strategy - to address
  complex causes and effects of disadvantage
• Fuel poverty strategy directed at vulnerable
  individuals and families
• Investment in early years development
  (Sure-start) and educational attainment

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CHANGE IN INCOME FOR RICH AND POOR UK BUDGETS
1997-2002
Gain/Loss income
Poorest 10
Richest 10
Institute for Fiscal Studies, 2000 (updated 2002)
(http//www.ifs.org.uk/taxben/fiscalreform.pdf)
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From analysis to action Consultation on a plan
for delivery

• Tackling Health Inequalities - Consultation on a
  plan for delivery (http//www.doh.gov.uk/healthine
  qualities/tacklinghealthinequalities.)

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Tackling Health Inequalities - Consultation on a
plan for delivery

• Key results Some strengths
• recognition of the complexity of the problem and
  its solution - especially the links to
  regeneration
• national targets and identified priority areas
  recognised and welcomed
• strong support for action taken so far and need
  for sustained action in the future - legitimising
  effect of activity

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Tackling Health Inequalities - Consultation on a
plan for delivery

• Key results Some challenges
• continuing gaps in the evidence and in its
  application
• fragility of local government and health systems
  as the foundation for action
• greater consolidation/co-ordination of activities
  needed
• missing vulnerable groups and critical issues -
  eg black and ethnic minority groups, older
  people, disabled people, mental health

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Cross-cutting spending review on health
inequalities

• Led by Treasury, technical support provided by
  Department of Health
• Focus on effectiveness of spending on
  services/programme across government on
  addressing the causes of health inequalities, or
  alleviating their effects
• Leading to binding proposals for modified and new
  spending for the period 2003-7 across most
  government departments

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Cross-cutting spending review on health
inequalities - use of evidence

• Acheson review findings re-examined by
  independent academics who conclude that they
  remain relevant and broadly accurate
• Apparent inverse relationship between volume and
  quality of evidence and potential effectiveness
  of interventions (evidence on upstream
  interventions particularly light)
• Social gradient not well understood (pressures
  for universal progress and addressing social
  exclusion remain key drivers in government)
• Analysis of relative costs and benefits of
  different forms of intervention very patchy.

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Cross-cutting spending review on health
inequalities

• Considerable existing activity that is not
  necessarily labelled as addressing health
  inequalities - need for greater coherence and
  continuity
• Tendency to see activities as marginal add-ons -
  challenge to influence the mainstream services
  and programmes of government departments
  (including and especially NHS)
• Key challenges to bend mainstream services,
  supplemented by dedicated programmes and services
  to address specific local need

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Cross-cutting spending review on health
inequalities - key themes

• 1. Breaking the cycle of health inequalities -
  addressing poverty, especially in families with
  children, healthy pregnancy, early childhood
  development (Sure-start), and educational
  interventions to close the attainment gap
• 2. Tackling the major killers - addressing the
  social gradient in modifiable behavioral and
  physiological risks, and in treatment service
  provision

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Key themes cont.

• 3. Improving access to public services and
  facilities - addressing the inverse care and
  provision law, especially in relation to
  primary care, and public transport
• 4. Strengthening disadvantaged communities -
  working with the grain of neighbourhood
  renewal, and regeneration strategies - improving
  housing, creating a safe environment, engaging
  public services in employment and education
• 5. Reaching vulnerable groups - working with the
  grain of social exclusion strategies to address
  the needs of fuel poor, mentally ill, rough
  sleepers, and prisoners and their families.

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Using structures and resources to create an
effective system for co-ordination and delivery

• At national level a cross-Department group of
  senior officials chaired by Treasury, and
  accountable to a Cabinet sub-Committee of
  Ministers for implementation of Delivery Plan
  DA(SER)
• NHS and Cross-government Delivery Plan structured
  around long-term targets to reduce the gap in
  health status between social groups and
  geographical areas

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Creating an effective system for co-ordination
and delivery

• At local level short to medium term targets for
  NHS (PPF) and local government (PSA)
• Publication of NHS performance and planning
  framework (Oct 2002) has embedded inequalities in
  the mainstream of NHS business
• Development of evidence-based standards for
  practice, supported by system for dissemination
  and workforce development (Health Development
  Agency)

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Providing a lead Key NHS interventions to reduce
gap in infant mortality

• Reduce teenage pregnancies
• Improving maternity services to secure early
  booking, attendance at ante-natal education
• Reduce smoking, improve nutrition in pregnancy
• Increase breast feeding initiation and duration
• Provision of early development support (including
  SIDS prevention) - link to Sure Start
• See - Improvement, Expansion and Reform the next
  three years - Priorities and Planning Framework
  2003-2006 (http//www.doh.gov.uk/planning2003-2006
  /index.htm)

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Providing a lead Key NHS interventions to reduce
gap in life expectancy

• Reduce smoking in manual groups
• Strengthen primary care in disadvantaged/
  under-served areas to ensure improvement in
  capacity for prevention, early detection and
  treatment of disease - focus on hypertension and
  obesity
• Reduce excess winter deaths by achieving flu
  immunisation and full contribution to fuel
  poverty strategy
• (http//www.doh.gov.uk/planning2003-2006/index.htm
  )

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Improvement, Expansion and Reform NHS Priorities
2003-2006

• NHS improvement, expansion and reform should
  narrow the health gap by
• ensuring that the distribution of health benefit
  from service expansion and development
  consistently favours individuals and communities
  that have been traditionally under-served,
• ensuring that service planning is informed by an
  equity audit and supported by an annual public
  health report by the Director of Public Health,
• (http//www.doh.gov.uk/planning2003-2006/index.htm
  )

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Improvement, Expansion and Reform NHS Priorities
2003-2006

• NHS improvement, expansion and reform should
  narrow the health gap by
• tackling the wider determinants of health -
  agreeing a single set of local priorities with
  local authorities and other partners,
  contributing to regeneration and neighbourhood
  renewal programmes, and ensuring the NHS makes a
  full contribution to support the Sure Start
  programme
• building capacity for public health improvement
  and protection in PCTs(http//www.doh.gov.uk/plan
  ning2003-2006/index.htm)

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Concluding remarks

• Much progress has been made in getting the
  policies right, and aligned
• Acheson Inquiry Report, Saving Lives - OHN, NHS
  Plan provide policy context
• Consultation on a plan for delivery added
  experience and intuition to existing evidence
• Cross-government Spending Review attempts to
  bring comprehensiveness and coherence - backed by
  resource commitments
• Current finalisation of a Delivery Plan
  specifying what, who and how much

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Concluding remarks

• Challenge is now to get funding and performance
  assessment/management systems (NHS, LPSAs etc)
  aligned to policy goals within culture of
  decentralised decision-making
• Maintain coherence within central government and
  foster local joining up
• Build capacity for effective local action