Published: 02/06/2005, Volume II5, No. 5958 Page 19

Allan Low asks why only spearhead PCTs should be measured on their success in reducing health inequalities

The public health white paper and subsequent delivery plan put the reduction of health inequalities at the top of the policy agenda, and assign primary care trusts a pivotal role. So pivotal, in fact, that the Healthcare Commission will include reductions in inequalities in health outcomes as one of the performance indicators in the annual PCT ratings.

But the assessment of reductions in inequality will not be applied to all PCTs - only a chosen few. These are the 'spearhead' PCTs - those in the bottom quintile on health and deprivation indicators.

But there seems to be no methodological or practical reason why only a small number should be performance managed on how they achieve equality targets.

Ministers and advisers have indeed emphasised the importance of not restricting examinations of health inequality to the extreme ends of the spectrum. Given this, the 'chosen few' approach to performance management of inequality reduction seems strangely at odds with policy.

This clear anomaly results from the way in which national health inequality targets have been set and the application of these to individual PCTs.

But this can be overcome by modifying the approach. The national health inequalities targets and the inequalities element of the national health improvement targets have been specified in terms of reductions in relative gaps between a target population and the national average.

This 'between' method of comparing should be replaced by one that assesses health gaps within populations - the 'within' approach.

Use of the within approach would enable nationally set health inequality reduction targets to be applied to all PCTs so they can all be assessed in the same way.

In the context of setting targets for reducing socioeconomic inequalities in health and managing the performance of PCTs in reducing health inequalities, the within approach has two main advantages.

First, it overcomes the anomaly of requiring all PCTs to reduce health inequalities within their populations while restricting performance management to only a few.

By contrast, using the between approach to set national targets such as reducing a health gap between the 20 per cent most deprived PCTs and the national average means that, at PCT level, the target can only apply to 20 per cent of PCTs.

But the within approach can be used to set common national targets for all PCTs. For example, there could be a national target to reduce relative health gaps across the country, expressed in terms of differences between the 20 per cent most deprived PCTs and the 20 per cent most affluent ones.

This same target can be applied at PCT level in terms of differences between the most deprived and most affluent wards within any PCT. All PCTs can then be performance managed on health inequality reductions, not just the spearhead PCTs.

The second advantage is that more inclusive measures of socioeconomic inequality can be used, which makes it possible to assess inequality across all PCTs. The technique has been used to monitor changes in inequalities in life expectancy across the country (BMJ , 30 April). It has also been used to monitor inequalities in a number of health conditions within PCTs ('Measure for measure', pages 26-27, 6 May, 2004).

Allan Low is a freelance health economist l Do you have an idea for Speak Out?

E-mail susan. delgado@emap. com