Addressing health inequalities in England: Implementing policies across central government

1. Addressing health inequalities in England: Implementing policies across central government Don Nutbeam Head of Public Health Department of Health

2. 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)

3. The Acheson Inquiry Report:Key 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

4. 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)

5. 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

6. 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

7. CHANGE IN INCOME FOR RICH AND POOR UK BUDGETS 1997-2002

8. From analysis to action: Consultation on a plan for delivery Tackling Health Inequalities - Consultation on a plan for delivery (http://www.doh.gov.uk/healthinequalities/tacklinghealthinequalities.)

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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.

16. 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

17. 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)

18. 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)

19. 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)

20. 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)

21. 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/planning2003-2006/index.htm)

22. 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

23. 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