More than half a dozen government departments will be expected to take action in response to Sir Donald Acheson's report on health inequalities, expected this month, with major roles allotted to the Treasury, the Department for Education and Employment and the Department for Environment, Transport and the Regions.
The NHS has a minor, though challenging, part to play: ensuring equitable access to effective care and more equitable allocation of its resources. Its most significant contribution will be in forming partnerships with local authorities and other agencies to establish local programmes to address health inequalities.
Inequalities targets will be highly relevant to the design of these programmes. Though excluded from the remit of the Acheson committee, the targeting issue is bound to be addressed by the public health white paper due out next year. There will be no national target on health inequalities, but local partnerships will be expected to set targets locally so that efforts and resources can be focused where they are most needed, and progress monitored towards explicit goals.1
But how are local inequalities to be identified? How are targets to be selected and how are they expected to feed into a national strategy? How is progress to be measured? Health authorities will need to consider these questions carefully.
Most obviously, health inequalities can be identified by means of mortality and morbidity rates and patterns of health service use, where data is relatively easy to come by. They can also be traced through factors known to influence health, such as income, lifestyle and environment, where reliable data is more elusive. Comparisons can be made between individual wards, between clusters of wards or between one partnership area and another. A geographical framework may be insufficient without comparisons based on ethnicity, age and gender.
Decisions about how to identify local inequalities (or which inequalities to identify) may be influenced by a range of factors. Which data is the most accessible or reliable? Where can changes be most easily achieved and progress demonstrated? Which problems should be most urgently addressed? Ultimately, the choice is political rather than purely technical.
The same is true of selecting targets. The HA or local health partnership must decide on the main function of the target. Should it be a broad mission statement or a measurable objective?
Many HAs have already set targets and these vary widely. Some are based on specific risk factors, such as smoking.
Others address the underlying determinants of health - as with Luton's bid for health action zone status, which named as one of its strategic objectives 'to enable a reduction in structural inequalities between groups of people and between communities in particular through improvements in economic development and housing'.
Health Promotion Wales decided to bring the infant mortality rate of all social groups up to the level of the best (below seven per 1,000 live births) by 2000. Some targets concern particular groups, such as ethnic minorities or neighbourhoods with a high level of deprivation.
A strategy that combines all three approaches may be the most effective.
HAs will need to consider how far any proposed target can be controlled by local agencies. And is there any evidence that intervention can be effective? How does the target relate to broader policy priorities at local, regional and national levels? Is there sufficient data to measure progress within an appropriate time scale?
There is some danger in 'cherry picking'. As the green paper Our Healthier Nation warns: 'Progress must not be secured simply by targeting social and ethnic groups whose health problems are more easily tackled.'
But one of the biggest problems with public health policy in general is persuading the public that local action can make any difference at all. Swift progress on one front may help to inspire confidence in the strategy as a whole. The need for short-term targets where 'quick wins' can usefully be scored must be reconciled with the need to tackle entrenched inequalities in the longer term.
By definition, selecting local targets is about prioritising spending. This can cause resentment if groups not targeted feel they are being treated unfairly or, conversely, if those who are singled out feel they are being stigmatised.
Lambeth, Southwark and Lewisham HA in south London has made it a priority to invest in supporting mothers, babies, children and young families. But it has had to acknowledge that this could be at odds with other priorities, such as reducing disease and disability for older people.
East London and the City HA has set a target of reducing unemployment among ethnic minority men aged under 25 to the level of the current best for any ethnic minority group in the area. Wherever resources are shifted to meet targets, there are bound to be winners and losers.
Relating local targets to national strategy
Our Healthier Nation has only four national priorities for action: heart disease and stroke, cancer, accidents and mental health. How should local inequalities targets relate to these? Dorset HA has chosen to target all four priorities and has set additional targets relating to maternal and child heath, sexual health (because of a relatively high incidence of teenage pregnancies in some parts of the county) and the management of chronic diseases, such as diabetes and osteoporosis, because of a preponderance of elderly people.
Should every local health partnership set four inequalities targets, one for each of the national priorities? Or, as current guidance indicates, should they be free to set their own local priorities?
If they set too many targets, resources may be spread too thinly. If they do not tackle inequalities relating to the national targets, strategies for dealing with heart disease and stroke, cancer, accidents and mental health could affect social groups differentially. How can the need for a consistent approach across the country be reconciled with the fact that inequalities vary between localities?
Making and measuring progress
Levels of experience in tackling health inequalities vary. In some parts of the country, there is little relevant experience. Elsewhere, including areas designated as healthy cities by the World Health Organisation, some valuable lessons have been learned. These need to be spread so that wheels are not re-invented.
But at the same time local health partnerships need scope to develop their own models and techniques, as home-grown strategies are more likely to command local commitment.
What matters most is how agencies work together. Will local authorities accept tackling health inequalities as a priority for local regeneration plans? Will health and local authorities develop useful common data sets? Will primary care groups take a broad view of health determinants, or cling to a narrowly medical perspective? Will local businesses, including food retailers, and voluntary organisations be integrated into the process? Will the public be sufficiently involved?
Finally, can agreement be reached on how to measure success and failure? A meaningful result for a GP or an epidemiologist may cut little ice with a local councillor or a community action group.
North West region's approach expresses its objectives not just in terms of outcomes, but in terms of the mechanisms and processes needed to tackle inequalities. This includes process targets (building partnerships, consulting the public, collecting data), activity targets (specific programmes, ranging from traffic calming to improving access to health services) and outcome targets (changes to specific health risks and disease and death rates among disadvantaged groups). Only in the latter case is epidemiological data used to track progress. What counts is evidence that policies have been put into practice.
There is also mounting interest in subjective 'quality of life' indicators, such as opinions about the local environment, and progress needs to be measured in terms that make sense to everyone concerned.
The NHS's most significant contribution to reducing inequalities will be through partnerships with other organisations.
Many health authorities have set targets and these vary greatly.
HAs need to consider how susceptible any target is to local action.
On the map: putting out indicators
Liverpool has produced a complex map of the city showing layers of information based on underlying determinants (including housing,
poverty, the economy, transport, crime, education and the environment), health outcomes (including standardised mortality ratios) and health service use (including emergency hospital admissions). Indicators are ranked and coded into three groups with the most desirable,
middling and least desirable scores.
Birmingham has chosen to focus on key indicators of health at different stages of the life cycle: low birth weight, teenage pregnancy, coronary heart disease and long-term illness in later life.
Manchester has conducted an equity audit for coronary heart disease, showing how the use of various interventions, including angiography and artery bypass, vary by area of residence, levels of deprivation and primary care settings.