Health Inequalities - Health Committee Contents


5  Specific health inequalities initiatives

112. Health inequalities have been known about for many years. Beveridge acknowledged the problem. The Black Report (1980) documented persisting inequalities. The Acheson Report, published in 1998, called for action on a broad front to tackle the problem[91] and prompted the Government's efforts to tackle inequalities over the past ten years.

113. During the course of this inquiry we heard widespread praise and support, both in this country and abroad, for the explicit commitment this Government has made to tackling health inequalities. This commitment has involved a framework of specific policies, underpinned by a challenging and ambitious target. We would like to emphasise our support and commendation for the Government for taking specific actions to tackle health inequalities, although, as we have written, we are critical of aspects of planning and evaluation. The Box below lists the Government's main initiatives to tackle health inequalities since 1997. This chapter considers these initiatives.

Chronology: Key reports and health inequalities initiatives

Acheson report - 1998
HAZ - 1998
Sure Start - 1999
Targets - 2000
Cross cutting review - 2003
Spearhead areas - 2004
National support team - 2006
Health inequalities intervention toolkit - 2006

Health Action Zones

114. Health Action Zones (HAZs) were the Government's first flagship policy to reduce health inequalities. HAZs were multi-agency partnerships located in 26 areas of England. The first wave of zones was launched in 1998 (15 areas) followed by a second wave (11 areas) in 1999. They varied greatly, ranging from large conurbations such as Merseyside and Tyne and Wear to largely rural areas such as Cornwall and North Cumbria. They were provided with fairly modest resources (approximately £4-£5 million per year per zone at 2004 prices), but expected to develop local programmes and activities to improve health and reduce inequalities during a seven-year lifespan.[92]

115. The three broad strategic objectives of HAZs were to:

  • identify and address the public health needs of the local area;
  • increase the effectiveness, efficiency and responsiveness of services; and
  • develop partnerships for improving people's health and relevant services.

116. The majority of initial programmes sought to improve health by promoting healthy lifestyles, improving employment, housing, education and tackling substance abuse. Another important set of activities focused on the health of particular population groups and/or specific health problems. But there was hardly any aspect of population health improvement or community regeneration that at least one of the HAZs was not concerned with in one way or another.

117. However, the HAZ programme was abandoned in 2003. Professor Ken Judge, who led the evaluation of Health Action Zones, opened his memorandum to the Committee with a stark summary:

Health Action Zones were conceived and implemented too hastily, were too poorly resourced and were provided with insufficient support and clear direction to make a significant contribution to reducing health inequalities in the time that they were given.[93]

He went on to describe the difficulties they faced:

HAZs were born at a time when anything seemed possible for a New Labour Government desperate to make things work and quickly. But the tide of enthusiasm for change outran the capacity to deliver it. Too many hugely ambitious, aspirational targets were promulgated. The pressure put on local agents to produce 'early wins' was debilitating. A sense of disillusionment began to set in relatively early in their lifespan, and HAZs soon lost their high profile as the policy agenda filled with an ever-expanding list of new initiatives to transform public services and promote social justice. By the beginning of 2003, much earlier than expected, they were to all intents and purposes wound up.

The evaluation found that the sheer complexity of the initiative and the extent of policy change that HAZs experienced meant that drawing simple conclusions about their impact was difficult. It suggested that there were some benefits: HAZs made a valuable contribution to building partnerships and raising awareness about inequalities in health and progress was made with individual programmes and projects. However, in general, the conclusions were negative, finding that HAZs made little impact in terms of measurable improvement in health outcomes during their short lifespan. HAZs did not—probably could not—do what they set out to achieve:

this was supposed to be a seven-year initiative, launched by one secretary of state, dramatically changed by the next, abandoned by the third, subject to different parliamentary and political timetables, where guidance from the centre was not clear, [or was] …contradictory. People competed with each other in terms of their aspirations. One of the Health Action Zones, which covered an entire conurbation and was given £4 million or £5 million a year, proposed to transform the life expectancy of the entire population such that it was in the top 10% for Western Europe in seven years. These things are simply not achievable.[94]

118. Professor Judge argued that the HAZ experience clearly demonstrated that there was a need to think more carefully about the focus of such initiatives, their objectives, their timescales, the support that they need both locally and nationally and the space, trust and time that is required to make any kind of sustainable change possible:

The notion that an injection of relatively modest resources accompanied by guidance—more evangelical than practical—from central government might result in the speedy resolution of major social problems, that had proved largely intractable for generations, would not find so many advocates today as was probably the case a decade ago. But HAZs were put under considerable pressure to demonstrate that they were 'making a difference' within a relatively short time period even though, as one contemporary commentator observed, 'early hits are not always evidence of accurate shooting'.

The overwhelming problem—evident in much contemporary policy research—is that the voracious appetite for intelligence by policymakers too often encourages the production of simple descriptions of activity, which are passed off as evidence of "good practice" without adequate discussion of the strengths and weaknesses of what is being presented. While undertaking the evaluation of HAZs we had serious concerns about the pressure to generate and use learning at too early a stage in the cycle of data collection, analysis and reflection. Simply documenting activity, which is frequently demanded and regularly served up, is not evidence of good practice and the growing tendency to pretend that it does yields little more than propaganda. Too many users of policy research still expect clear answers about impact when a more realistic product of evaluations is that they contribute to a process of enlightenment about highly complex processes that are interpreted by different actors in multiple ways.[95]

CONCLUSION

119. Health Action Zones were an ambitious initiative that could not achieve the extremely challenging targets that were set for them in the short time they were in existence. We have heard that they were a victim of many of the problems with policy design and implementation documented previously—they were both under funded in relation to their objectives, and ill-thought through.

Sure Start

120. According to many of our witnesses, the impact of the early years on health inequalities cannot be overstated. A mother's lifestyle whilst pregnant can affect her child's future health. Lifestyle factors once a baby is born, including breastfeeding, diet, and smoking in the home, can also impact upon future health. Postnatal depression can have long-term effects on children's behaviour and parenting skills can influence later educational performance, which itself affects their later life.

121. The importance of early years was emphasised in the Acheson report, and the Government has set an ambitious target to halve the number of children living in poverty by 2010 and to eradicate child poverty by 2020. The extent of child poverty is roughly defined as the children in households which have below 60% of 'median incomes'. Although rates of child poverty are reducing, the 2004-05 target was missed, and projections suggest that the 2010-2011 target will also be missed.

122. The Sure Start programme was launched in 1999 to provide support to disadvantaged families in the crucial early years It aims to achieve better outcomes for children, parents and communities by:

The evidence that informed the creation of Sure Start came from the United States, where early years programmes had demonstrated a decrease in the incidence of behavioural problems, psychological disorders and special educational needs, usually apparent by adolescence. However, there are fundamental differences between Sure Start as it was eventually implemented and the American programmes on which it was loosely based.[96]

123. Below we look at a number of aspects of Sure Start, namely:

  • Has Sure Start worked?
  • Reasons for success and failure: variations in Sure Start programmes and links with NHS early years programmes
  • The future: should Sure Start provide targeted or universal services

HAS SURE START WORKED?

124. Witnesses from individual Sure Start programmes gave us several examples of individual initiatives introduced in their areas which they felt had worked well. These included training parents to be community workers and to offer support to other parents; providing an integrated programme of support for teenagers; an initiative run jointly with the local council to increase levels of physical activity; and the establishment of a community engagement team.[97]

125. The first major evaluation of Sure Start was published in June 2005, and showed evidence of benefit in the less deprived families, but little benefit in those with the greatest needs.[98] The next evaluation (2008) was more positive.[99] This showed that there were some benefits to living in a Sure Start Local Programme (SSLP) area. Children living in such areas exhibited more positive social behaviour and greater independence/self-regulation than children in non-Sure Start areas, whilst parents made greater use of support services, exhibited less negative parenting and provided a better home-learning environment. Families living in SSLP areas also used more child- and family-related services than those living elsewhere.

126. Unlike the 2005 study, the second study, published in 2008, showed beneficial effects for almost all children and families living in SSLP areas and provided almost no evidence of adverse effects on population sub-groups, such as workless or lone-parent families. The effects associated with SSLPs appeared to apply to all of the resident population, whereas the earlier 2005 study found positive and negative effects for different subgroups.

127. However, the evaluation was not all positive: of the 14 outcomes measured relating to health and child development, Sure Start programmes were only found to have an impact on five; they did not have a positive impact on children's immunisations, accidents, language development, mother's rating of area, father's involvement; maternal smoking, maternal body-mass index, or maternal life satisfaction.[100] Moreover, it is difficult as of yet to link improvements in children's behaviour and in parenting skills to long term improvements in health or narrowing of health inequalities.

128. Separate research undertaken by Hull University concluded that Sure Start, despite being targeted at deprived areas, was still not benefiting the most deprived and marginalised populations within those areas:

Too often SSLPs took a whole population approach when social and economic indicators suggested that they should be targeting specific minority communities. Although some programmes had an effective structural approach to minority groups, the majority were tending to respond in an ad-hoc, short-term way and often did not reach families who needed help. This was particularly true of groups described as 'hard-to-reach': very small populations, groups of travellers/gypsies/Roma, migrant workers, families of Bangladeshi origin.[101]

129. A local evaluation had, according Frances Rehal, Director of Millmead Sure Start, demonstrated progress in more defined, health-related outcomes:

When we started our programme in 2000, 27% of mums breastfed their babies at birth; the figure now is around 57%. In teenage births within the Sure Start area over the past nine years, and that was four prior to Sure Start and five post Sure Start, we were able to evidence 65% reduction in teenage births. When we started out, 52% of our children failed to attend speech and language therapy sessions to which they had been referred. Now, after our programme funding research into the causes of non attendance, our figure is under 5% non-attendance.[102]

130. However, this is a very small scale piece of research and cannot be taken as definitive evidence of benefit. Professor Melhuish concluded that while some benefits in child development and parenting have now been demonstrated, much is still unknown about the impact of Sure Start, particularly its cost effectiveness:

We are finding the children who are born around about 2003 and 2004 are now showing some improvement in their development where they have been in Sure Start programmes and parenting practices in Sure Start programme areas seem to be better. In that sense, they are having benefits. Are they value for money? Could we have spent the money in other ways which would have produced more benefits? That is still an open question, I think.[103]

REASONS FOR SUCCESS AND FAILURE

Variation

131. In Chapter 3 we described the difficulties brought about by differences in local implementation—both for the effectiveness of the programme, and for evaluating it. Professor Melhuish drew attention to the great variation between the Sure Start programmes of different areas:

there was great variation in Sure Start programmes. Some are very effective and some are comparatively ineffective[104]

132. In Professor Melhuish's view, the lack of guidance and direction given to those initially charged with implementing the Sure Start programme was a mistake:

Communities had almost complete control at the start about how they delivered their programmes, which led to the enormous diversity we saw across the country in the early Sure Start programmes. There should have been published some guidelines about the kinds of services to be delivered at the early set up. Apparently those guidelines were written but did not get distributed to the programmes, and so there was this enormous diversity of set up.[105]

This made it much more difficult to evaluate Sure Start and may have led to deviations from the original, evidence-based model on which the programme was based.

Maintaining links with NHS early years services

133. Sure Start aims to integrate early years education, childcare, parenting programmes, health promotion, and early years health services. Professor Melhuish told us that his evaluation showed a general tendency for Sure Start programmes which were well integrated with local health services to have the most effective outcomes:

There is very good reason for this. The health services give you immediate access to parents in pregnancy and children at birth, and, therefore, the Sure Start programmes can get into contact with those families very early on. Where that integration of health services with Sure Start programmes does not take place, Sure Start programmes are often at a loss to know who has had a new baby in that area, whether that new family needs help or not. Any ideal services, I would suggest, would involve very close integration of the health services with Sure Start type programmes. Currently, this is very patchy across the country. Some programmes have excellent integration of health services; for example health visitors working closely with the Sure Start programmes … Where this does not happen, problems tend to get worse and worse as time goes on.[106]

THE FUTURE: TARGETED OR UNIVERSAL CHILDREN'S SERVICES?

134. After providing six years of targeted support in the most deprived areas, Sure Start programmes are now being subsumed into Children's Centres, which by 2010 will be universal. Witnesses thought this development might create a number of problems. Professor Melhuish argued that putting Children's Centres under the auspices of local authorities had dislocated children's services from the NHS.[107]

135. We also heard concerns that Sure Start programmes were being 'colonised' by the middle classes, who enjoyed the cheap, high quality childcare they offer and that extending provision universally would further dilute their focus on those who need them the most. The Secretary of State for Health did not think this was a problem:

The fact that children's centres are going into areas that are more affluent is not in any way detracting or diluting from the focus in deprived areas to get to the hardest-to-reach people.[108]

136. However, he did not give us a clear explanation of why the policy was being extended, nor what was being done to ensure the focus on deprived families was preserved.

CONCLUSION

137. The early years period was emphasised throughout our inquiry as a crucial focus for efforts to tackle health inequalities, and we commend the Government for taking positive steps to place early years at the heart of the health inequalities agenda through Sure Start. Many witnesses were very positive about the benefits of Sure Start. National evaluation shows that it has enjoyed some success, but it has yet to demonstrate significant improvements in health outcomes for either children or parents, achieving positive evaluation in only 5 out of 14 measures that were studied.

138. Moreover, there is concern that extending this policy, via Children's Centres, to all areas of the country, risks distracting from the original focus of deprived families who are most in need of support. We did not receive detailed evidence about the evolution of Sure Start programmes into Children's Centres, but again this is a policy change that has not been properly piloted or evaluated prior to its introduction. It is absolutely essential that early years interventions remain focused on those children living in the most deprived circumstances, and Children's Centres must be rigorously monitored on an ongoing basis.

Targets and the Cross-Cutting review

139. The NHS Plan (2000) announced the first ever national health inequalities targets for England. These were reaffirmed in the Comprehensive Spending Review as:

to reduce inequalities in health outcomes by 10% by 2010 as measured by infant mortality and life expectancy at birth.[109]

140. In measuring progress against this target, the Government has chosen to focus on inequalities as measured by socio-economic class rather than education, ethnicity or any of the other ways in which health inequalities can be measured.

PROGRESS TOWARDS MEETING THE TARGET

141. The Department's 2008 Annual Report notes that "it will be challenging to meet all aspects of the PSA target". In fact, since the baseline period (1995-97) the gap between the 'routine and manual' groups and the population as a whole has widened. The gap in men's life expectancy in the period 2005-07 was 4% wider than the baseline period, while for women, this gap was 11% wider. From 2004-06, infant mortality in routine and manual groups was 17% higher than in the population as a whole, compared to 13% in the baseline period.[110]

142. Despite this, the Secretary of State for Health remained optimistic in his appraisal of progress, arguing that the full impact of some policies had not yet been felt, and that by 2012 progress would be better:

I do not think the full effects of smoke-free legislation, for instance, has fed through yet. There will be some effects from GP surgeries going into under-doctored areas. We will not know until 2012. That is when we will find out if we have made the 2010 target. I still think we can make it …As I say, I do not have heroes and villains here. There is no PCT that I have been to—and I go around the country an awful lot—where I think, "They're just not interested in health inequalities." There are areas where they do not have the partnership right and there are areas where in the local strategic partnership they are not playing the active role that they should, but they all want to tackle this issue. As Hugh just quoted, the figures for people who are aware of this challenge and are aware of our targets and all the rest of it, amongst local authority chief executives is very high and very encouraging. I think we can do it.[111]

143. However, the Healthcare Commission, the body which monitors the NHS's progress against government targets, argues that it is highly unlikely that this target will be met:

Performance to date would suggest that current health inequality PSA targets will not be met.

CRITICISMS OF THE TARGET

Should the target focus only on socio-economic inequalities?

144. As we have discussed in Chapter 2, health inequalities are evident across a number of different measures—not only socio-economic status, but ethnicity, gender, age, disability and regional area. This suggests that health inequalities should perhaps be measured and targeted in a multidimensional way. There is evidence that some PCTs are already doing this. Alwen Williams, Chief Executive of Tower Hamlets PCT, told us:

For us, given our population, issues of ethnicity are key. One of the challenges the NHS has is: how do we measure, so we can measure the impact of what we are doing in relation to the different population groups within our communities? We have implemented, for example, patient profiling in our general practices so that we are starting now to measure ethnicity in a much more comprehensive way. That will help us ensure we can then measure equity of access, equity of health outcomes in relation to some of those factors that are part and parcel of our population make-up. We are not doing that because that has been a target set for us: that is because we understand that for us to be successful in what we are trying to do around health improvement that is a key component—for us to be able to understand and measure our achievements and successes in future years.[112]

Should infant mortality be in the target

145. As mentioned above, we were told by the ONS that as numbers of infant deaths are now so low, it is very difficult to discriminate between areas in a statistically sound way, as only a couple of random occurrences of infant deaths are needed to invalidate this. This raises questions about whether infant mortality is a valid way in which to measure health inequalities and whether it should be included in the target.

Timeframe

146. Some witnesses told us that ten years was an insufficient timeframe to achieve this level of change; Professor Sir Michael Marmot, Professor of Epidemiology and Public Health at University College London and Chairman of the Commission on Social Determinants of Health, argued that a more realistic ambition would be 'closing the health gap in a generation'.[113]

Inequalities or the health of the poorest?

147. As discussed previously, the trend of widening health inequalities does not mean that the health of those in the lowest socio-economic groups is getting worse. In fact, life expectancy amongst the lowest socio-economic groups continues to increase. Inequalities have worsened not because the health of the poor is getting worse or even staying the same, but because the rate of health gain is faster amongst more advantaged groups.

148. On visits to Norway and the Netherlands, we heard that in having a target which explicitly aims to reduce inequalities rather than simply improving the health of the poor, England has one of the toughest targets in the world. It was suggested that a better approach to improving health might be a focus on improving the health of the most disadvantaged groups rather than on narrowing differences. Professor Julian Le Grand, Chairman of Health England, agreed:

One should focus on the absolute level of ill-health of the poor. One of the pieces of advice I gave the Government a very long time ago was that setting a target in health inequalities is almost certainly a mistake, because almost certainly you will miss it—and, indeed, that is exactly what has happened.[114]

149. Professor Ken Judge, Head of the School of Health at the University of Bath, did not believe that the target has provided sufficient focus in this area:

Certainly in England the view has been, and the pressure from the public health lobby on the Government at the time was, that the adoption of targets would help to focus efforts and drive through change-agendas which deliver more progress. There is little evidence that has been the case in the last seven or eight years, I am afraid.[115]

150. Others, however, maintained that having an 'aspirational' target such as this was instrumental in galvanising policy makers towards targeting this area. The Healthcare Commission argue that missing the target should not be viewed as failure, arguing that:

Without these targets, the situation would have been worse. In combination with the health inequalities elements of other related targets, the target has provided a focus for commissioners and service providers and has driven improvement in several areas including teenage pregnancy, infant health, tobacco control and life expectancy. We therefore congratulate Government on setting the target and establishing a Health Inequalities Unit. These were brave decisions and gave a strong message, raising the profile of health inequalities and adding to the debate.[116]

151. The Secretary of State was firm in his defence of the adoption of such a difficult and possibly unrealistic target:

It would give us an easier life but I think it would be depressingly unambitious just to say, "Let's target the poor and forget about the inequality gap."[117]

Promoting short-term measures?

152. Concerns were voiced about the way in which the target is measured, skewing efforts to tackle health inequalities. Some witnesses argued that the targets, and indeed the measures recommended by Government to achieve them, focusing predominantly on treating CHD in the over-50s, might actually divert effort and funding away from more long-term and potentially more valuable interventions focused on preventing ill-health in today's children and young people.[118] On the other hand, it might be perverse not to treat CHD in the over-50s since it is one of the few interventions which is known to work.

Focus on the most deprived or other groups

153. The target focuses on improving the health of the most deprived section of the population relative to the population average, but inequalities occur across the whole of the population; the higher an individual's socio-economic group, the better his or her life expectancy. A case can be made for setting a target which raises all other socio-economic groups relative to the highest. This may be more cost-effective as middling socio-economic groups might be more receptive to a range of policy instruments.

Neglecting local inequalities?

154. Efforts to meet the national target, which compares average rates for the whole PCT against national averages, may also mask inequalities that exist within deprived PCTs, as well as neglecting pockets of deprivation that exist in more affluent PCTs. Alwen Williams, Chief Executive of Tower Hamlets PCT told us:

We can do the comparison of Tower Hamlets versus other PCTS in our Spearhead group over the rest of the country, but actually if we look at men living in Bethnal Green and men living in Millwall, there is a difference of eight years in terms of life expectancy. There are some interesting statistics and we are looking a bit more at this; but looking at Spitalfields, which is predominantly a Bangladeshi community, the life expectancy there for women is higher than the national average; so we have actually got some unexpected statistics[119]

155. As the Healthcare Commission pointed out in its written evidence, focusing on improvements in only the most deprived areas would not address health inequalities fully, as there were pockets of deprivation in all areas. The HCC, in its recent review of PCTs' efforts to improve smoking cessation, found that many PCTs, especially those in more affluent areas, were not yet successfully targeting small areas or population groups known to have high levels of smoking.[120] We were also told that in a PCT it is actually very difficult to deliver targets based on social class, as the data may not exist, often locality (eg index of multiple deprivation) and/or ethnicity are used as alternatives.

THE CROSS-CUTTING REVIEW

156. Since 2000, the Department has published a series of action plans and reviews aimed at bolstering progress towards the target. The Cross-Cutting review, led by the Treasury and published in 2002, aimed to co-ordinate action across Government departments. In response the Department of Health published Tackling Health inequalities—a programme for action in 2003, which set out a total of 82 indicators measuring factors which would contribute to reducing health inequalities, underpinned by 12 'headline' indicators against which progress would be systematically reviewed.[121]

157. The Department of Health's progress report, Tackling health inequalities—2007 status report on the programme for action, which was published in March 2008, presents a positive view, stating that of 82 departmental commitments to support the national health inequalities strategy, 72 have now been met.[122] Unfortunately, although the most of the 82 department commitments have been met, health inequalities are widening, and of the 12 'headline' indicators, only a handful have demonstrated progress in reducing inequalities between social classes. In some areas inequalities have actually widened.

Progress against 12 national headline indicators[123]
Indicator Progress
Death rates from the big killers Cancer—no significant change in relative inequalities
Heart disease—widening in relative inequalities
Rate of under-18 conceptions No significant change in relative inequalities
Road accident casualty rates in disadvantaged communities No significant change in relative inequalities
Numbers of primary care professionals No significant change in relative inequalities
Uptake of flu vaccinations Slight narrowing of inequalities
SmokingManual groups—some signs of a widening in relative inequalities
Pregnant women—some signs of a widening in relative inequalities
Educational attainment Some signs of a narrowing in inequalities
Consumption of fruit and vegetables No significant change in relative inequalities
Proportion in non-decent housing Narrowing of inequalities
PE and school sport In 2006/07, participation in PE and school sport in School Sport Partnership schools with a high proportion of pupils eligible for free school meals (FSM) is on average almost the same as in other schools
Children in poverty The proportion of children in England living in low-income households has fallen since the baseline of 1998/99
Homeless families living in temporary accommodation Since March 2002 there has been a reduction in the number of homeless families with children in bed and breakfast (B&B) accommodation

158. In a damning description of the status report, Hilary Graham, Professor of Health Sciences at the University of York, told us that the 2003 Cross-cutting review had simply shoehorned existing policies into the health inequalities agenda, without proper consideration of what would work:

the indicators, the 75 of the 82 successful indicators, the basket of indicators, came from the Treasury-led review of strategies—the Programme for Action strategy to tackle inequalities—and by and large it was an attempt to map existing initiatives against the targets; namely, given that this is what we are doing, how might they contribute to reducing inequalities? I think there is an opportunity to turn the question around the other way and say, "If we want to reduce inequalities in health, what should we be doing in policy terms?"[124]

CONCLUSION

159. It is likely that the Government's health inequalities target will be missed. This is unsurprising since it is the toughest target adopted anywhere in the world. Despite this likelihood, we agree with the HCC that aspirational targets such as this can prove a useful catalyst to improvement. We commend the Government for its adoption of this target and we recommend that the commitment be reiterated for the next ten years.

160. Health inequalities have many facets—health is unequal according not only to social class, but to gender, ethnicity, age, disability and mental health status, to name only a few. It is crucial that the Government's focus on socio-economic inequalities alone does not lead to other aspects of health inequalities going unnoticed and ignored. We were pleased to see that some local areas already focus on health inequalities related to ethnicity as appropriate to their local populations; however there is little to suggest that health inequalities relating to either gender, age or to mental health status are even being adequately measured let alone addressed. A wider range of inequalities should be measured. Such measurements should include not just unequal outcomes in terms of length and quality of life, but should also examine unequal access which would lead to unequal outcomes. We have also heard that there are statistical problems with the infant mortality target because there are so few infant deaths in each area. We recommend that this target be reconsidered. We recommend that the best ways to measure and target health inequalities be investigated by Sir Michael Marmot's forthcoming review.

161. In 2003, the Treasury's Cross-Cutting review set out a seemingly ambitious plan of action across government departments to tackle health inequalities; however, we were told that this was simply an attempt to "map existing policies" on to the target, with little thought given to what would actually work. Five years on, the measures listed in the Cross-Cutting review have not delivered what they promised—although almost all the indicators have been achieved, we are still as far as ever from actually reducing health inequalities.

Support for 'Spearhead' areas

162. Action to meet the target has been focused on the 'Spearhead Areas'—the 70 local authority areas with the worst health and deprivation indicators. However, according to Dr Anna Dixon, Director of Policy for the King's Fund, giving certain PCTs/ LAs 'spearhead' status has not been an effective lever to galvanise people to action:

From some analysis that we have done, the identification of the spearhead local authorities has not meant a great deal on the ground. Obviously it was an important way of measuring against the target in terms of life expectancy but, particularly in those local authorities that have been designated spearheads, there has not really been a sense—and we did some interviews with directors of public health and others working in local government—that spearhead status had really made much difference in their focus on health and health inequalities, which is clearly quite disappointing.[125]

163. This view was endorsed by Dr Jacky Chambers, Director of Public Health at Heart of Birmingham PCT:

I think the awareness of Spearhead and the extent to which it has got a profile in the city is probably quite low, if I am honest, in terms of it as a vehicle, and although the Spearhead local authority is a network and the conference that kick-started that, I think the reality is that in terms of the kinds of support that we have received by way of sharing good practice and networking has not really had all that much in the way of impact. We have basically got on with it. We have enjoyed having that status and we have enjoyed having the National Support Team visit but other than that I cannot say that it has really added much.[126]

164. Dr Dixon also pointed out that the spearhead areas that have made the most progress in tackling health inequalities are those that were already the least deprived in that group:

those who have performed best were already the ones that were least deprived. It does seem that those spearheads which met all five of the criteria to get that status have been the really toughest ones in term of their improvement.[127]

THE NATIONAL SUPPORT TEAM

165. Faced by the failure to reduce health inequalities, in 2006 the Department of Health created the National Support Team (NST) on health inequalities, to work with local authorities and PCTs in the spearhead areas. The NST "explores the local context and systems and promotes the success factors for delivery and shares good practice on both aspects of the target".[128] The Secretary of State for Health described the value of the support team:

I think the major important element here are these national support teams. This is a systematic, evidence-based, scientific approach that we are developing here. We find that PCTs need some help in Spearhead areas in particular—not exclusively, but in particular. The national support teams have been very, very popular. We had only one national support team and now we have doubled that to two, which means that we can get them around to every Spearhead area by the summer of next year. What do they do? They go into these areas and they systematically look at the issues. They concentrate attention on smoking, on cholesterol, on cardiovascular disease, and they help the PCTs.[129]

166. The adoption of a specialised, unevaluated but popular, support team half way through the target's ten-year period is an implicit criticism of the failure to provide central support as soon as the targets were established. The contrast to the Teenage Pregnancy strategy is striking. In this strategy local co-ordinators received close support, guidance and management from a central unit from its launch. Spanning the same period as the health inequalities strategy, the Teenage Pregnancy Strategy has had more success; despite last year's rises, it has achieved a 6.4% reduction in under 16 conceptions and a 10.7% reduction in under 18 conceptions since its baseline period, where over the same period there has been an increase in health inequalities.[130]

THE HEALTH INEQUALITIES INTERVENTION TOOL

167. In addition to the National Support Team, the Health Inequalities Intervention Tool was introduced to identify the interventions most likely to contribute to meeting the health inequalities target in each PCT area. It also "encourages partnership work with local authorities to promote the wider, social and environmental improvements on health inequalities."[131]

168. For the life expectancy element of the target, the Health Inequalities Intervention Tool has meant focusing on high impact medical interventions, particularly among the over 50s, on reducing smoking among manual groups and on the prevention, effective management and treatment of other cardiovascular risk factors through primary care, particularly control of cholesterol and blood pressure.

169. Rather than identifying specific interventions, for the infant mortality aspect of the target, the Tool identifies contributory factors that may reduce infant mortality, including preventing teenage pregnancy, reducing smoking, maternal obesity and the incidence of sudden and unexpected deaths in infancy. The importance of early antenatal booking is also highlighted, although there is little evidence linking this specifically to reductions in infant mortality or any of the contributory factors identified above.

CONCLUSION

170. Despite much hype and considerable expenditure we have not seen the evidence to convince us that any of the specific support given to deprived areas to tackle health inequalities has yielded positive results. Spearhead status on its own appears to have done little to galvanise areas to tackle health inequalities. Support is now being offered by the National Support Team, but although PCTs have welcomed this, there is little evidence to suggest it is or will be an effective intervention. We are also concerned that this was only introduced six years after the target was announced, and we consider that it would have been more logical and effective to have offered central support to PCTs to achieve this critical target right from the beginning.


91   Independent Inquiry into Health Inequalities, TSO, 1998 - http://www.archive.official-documents.co.uk/document/doh/ih/contents.htm  Back

92   HI 34 - Professor ken Judge Back

93   HI 34 - Professor Ken Judge Back

94   Q 360 Back

95   Ev 103 Back

96   Q 369 Back

97   Q 391 Back

98   http://www.ness.bbk.ac.uk/impact.asp  Back

99   http://www.ness.bbk.ac.uk/documents/activities/impact/41.pdf  Back

100   Sure Start Local programmes in England, The Lancet, Volume 372, Issue 9650, Pages 1610-1612, 8 November 2008  Back

101   http://news.bbc.co.uk/1/hi/education/6287610.stm  Back

102   Q 370 Back

103   Q 377 Back

104   Q 372 Back

105   Q 382 Back

106   Q 372 Back

107   Q 375 Back

108   Q 1258 Back

109   HI 101 Back

110   Tackling Health Inequalities: 2005-07 Policy and Data Update for the 2010 National Target, DH, 2008; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091414 Back

111   Q 1200 Back

112   Q 211 Back

113   Q 153 Back

114   Q 457 Back

115   Q 342 Back

116   Ev 293 - Healthcare Commission Back

117   Q 1189 Back

118   Ev 293 Back

119   Q 218 Back

120   Ev 290 Back

121   Tackling Health inequalities - a programme for action, Department of Health, 2003; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008268?IdcService=GET_FILE&dID=10311&Rendition=Web  Back

122   Tackling Health inequalities 2007 status report on the programme for action, Department of Health, 2008; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083471  Back

123   Tackling Health Inequalities: 2007 Status Report on the Programme for Action, DH, 2008 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083471 Back

124   Q 95 Back

125   Q 97 Back

126   Q 260 Back

127   Q 97 Back

128   HI 01 Back

129   Q 1193 Back

130   http://www.everychildmatters.gov.uk/resources-and-practice/IG00200/  Back

131   HI 01 Back


 
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