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Recent developments in health inequalities policy

Country: 
United Kingdom
Partner Institute: 
London School of Economics and Political Science
Survey no: 
(13) 2009
Author(s): 
Oliver, Adam
Health Policy Issues: 
Funding / Pooling
Others: 
A range of initiatives to reduce health inequalities, at the policy paper stage
Reform formerly reported in: 
Progress towards health inequalities targets
Policies towards reducing health inequalities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

Health inequalities policy is once again receiving a lot of attention in UK health policy circles, particularly in the wake of the report by the WHO Commission on the Social Determinants of Health. The Chair of that report, Sir Michael Marmot, has been invited by the Government to chair a further review on how to tackle health inequalities in England by 2015. This HealthPolicyMonitor Report will provide an update on recent actions taken to try to address health inequalities.

Recent developments

The health inequality targets around infant mortality rates and life expectancy that the Government set at the beginning of the decade (with the intention that they would be met by 2010), are unlikely to be achieved. Probably partly as a consequence of this, the Government has over the last few months renewed its efforts to reduce inequalities in health. 

In November 2008, the Government announced that it had invited Sir Michael Marmot, Chair of the recently published report by the WHO Commission on the Social Determinants of Health, to lead a review of what actions ought to be taken to reduce health inequalities in England by 2015. That review is still ongoing. In announcing the review, Alan Johnson, the Secretary of State for Health, stated that he was "asking Michael Marmot to review our position and investigate whether it is possible to eradicate health inequality altogether." This statement is interesting (and somewhat strange), because eradicating all health inequality would very clearly be an impossible task (after all, the Government has failed to meet its quite modest health inequalities targets over the last ten years), and attempts to do so would require such severe restrictions on individual liberty that we would risk creating a society in which no one would wish to live.  

The stated objective of the new review is to identify aspects of the WHO Commission report that are relevant for England and to work with national and local stakeholders to achieve short term and longer term outputs by 2015 and 2020. Specifically, the review aims to identify the health inequalities challenge facing England and review the evidence that is most likely to meet this challenge, to show how the evidence can be translated into policy, to advise on possible objectives and measures, and to publish the review's work. If all this sounds familiar, that's because it is: the objectives are similar to those adpoted by the Acheson review back in 1997, and before that the Black review in the late 1970s. 

Aside from the new Marmot review, the Government also announced in November 2008 that it was allocating £13.5 million to improve health in disadvantaged areas. £13.5 million is of course a tiny amount of money in the grand scheme of things, and is a sum that is unlikely to have a significant impact, but it comprises two specific types of investment. First, £11 million is being directed towards the "Communities for Health" scheme, whereby 83 geagraphical areas will be helped to implement local improvements in parenting, healthy eating, and community activities for the young and the elderly. Second, £2.5 million will go to the "Healthy Communities" initiative, which aims to improve knowledge in local governments on how to tackle local health inequalities via leadership and corporate development.

The Government has announced that these initiatives will serve to support the recently announced "Change4Life" programme, which aims to (among other things) help support corner shops to provide fresh healthy food (which, perhaps not coincidentally, is a policy that is also being proposed by the Obama Administration in the US). The emphasis here seems to be to try to encourage local communities to 'help themselves' to tackle, what Julian Le Grand would call, the 'Giants of Excess' (i.e. obesity, smoking, drugs and alcohol).  

Finally, the Government (also in November 2008) announced an extension of its 'Pacesetters' programme (initially implemented in 2007), which aims to improve health and wellbeing in deprived areas. The Department of Health stated that there have been a number of successful projects in the initial stage of the programme, which included increasing breast cancer screening rates in some areas, and improving the hospital experiences of those with learning disabilities. The second, new, wave of the programme aims to have an impact on families affected by diabetes, cancer and cardivascular disease (i.e. some of the biggest killers, which, if one really wants to address health inequalities, have to be the focus).     

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent rather system-neutral system-neutral
current current   previous previous

As in previous reports.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Initiators of idea/main actors

  • Government
  • Opinion Leaders
  • Political Parties

Stakeholder positions

A key player in the re-emphasis on tackling health inequalities is, I suspect, the current Secretary of State for Health, Alan Johnson, who does seem to be very engaged with and concerned about circumstances in disadvantaged communities. The (probable) failure to meet the previous health inequality targets has also probably to some extent shocked the Labour government who are now fighting for their political survival, and are headed by a leader (Brown) who is more innately left-leaning than was the previous leader (Blair - incidentally, now the highest paid public speaker in the world). 

The various initiatives outlined about involve various stakeholders. All have been initiated by the central government, but all will require the involvement of local communities, local governments, PCTs, providers and other local players if the proposals are to be successfully implemented. The Marmot review team is comprised of many opinion leaders/academics, who will clearly have an influence on shaping the proposals, although the extent to which a Conservative Government, if elected in 2010, will embrace the proposals is unclear at this time. It is likely, however, that a future Conservative Government will not be concerned with health inequalities to the extent that the current Government seems to be.  

Actors and positions

Description of actors and their positions
Government
Central governmentvery supportivevery supportive strongly opposed
Local governmentvery supportivesupportive strongly opposed
Opinion Leaders
Several academicsvery supportivesupportive strongly opposed
Political Parties
Labour Partyvery supportivesupportive strongly opposed
Conservative Partyvery supportiveopposed strongly opposed
current current   previous previous

Influences in policy making and legislation

I don't think there will be a leglisative process around this. Many of the initiatives outlined above have been implemented. The Marmot review is currently ongoing, but its recommendations will presumably be considered by the current Government when they are released. As noted above, a future Conservative goverment is less likely to act on the proposals.

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Government
Central governmentvery strongvery strong none
Local governmentvery strongneutral none
Opinion Leaders
Several academicsvery strongneutral none
Political Parties
Labour Partyvery strongstrong none
Conservative Partyvery strongweak none
current current   previous previous
Central governmentLocal government, Several academicsLabour PartyConservative Party

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

I think I have outlined this as far as I can above. Implementation will depend upon actors at the local level for many of the initiatives, and this will in turn probably depend upon available funding. At this stage, I don't see clear losers, other than the perennial question of opportunity costs that hovers above all policy decisions. We will have to wait to see who are the clear winners and losers (if any) of the Marmot review recommendations, but one may surmise that those recommendations are likely to involve some redistribution of resources from the rich to the poor (they will have to do, if they are to address health inequalities).

Monitoring and evaluation

There are no strong results yet. There are some indicative positive results for some of the quite small initiatives in the Pacesetters initiative. For example, in Walsall (a relatively poor town in the West Midlands, near Birmingham), of women with learning disabilities who agreed to breast screening, 100% have now been screened, compared to a national average of 17%. One should be careful with drawing inferences from these figues, because it likely to be small sample from a particular geographical area, it is not an RCT or even a good 'before and after' study etc. But it may show some indication of a positive effect.

Expected outcome

I applaud the current Government's intentions (which I think are well meant) in trying to refocus on this area, but I'm not overly optimistic about the future outcome. Even if the current Government does win the next general election, health inequalities are very difficult to tackle in a modern developed nation, where most groups, by and large, do have reasonable health indicators anyway. It may prove more fruitful to try to 'raise the floor' rather than narrow the distribution of health inequalities.

Also, a recent Parliamentary Report on health inequalities (published in March 2009) concluded that the Government's efforts to tackle health inequalities are "being held back by inadequte policy evaluation", and "money has been spent on initiatives that might not even work." It is of course possible that the Government will respond effectively to the Parliamentary Report, but as I said above, I'm not overly optimistic.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high
current current   previous previous

I can't really comment on the actual impact yet - this is obviously an empirical question and we'll have to wait and see. But so far, the Government has not met the health inequality targets (by income, over infant mortality and life expectancy at birth) that it has set itself in the past (when, unlike now, it had huge parliamentary majorities and a very strong economy - so don't hold your breath).   

References

Sources of Information

World Health Organization. Social Determinants of Health. www.who.int/social_determinants/en/.

House of Commons Health Committee. Health Inequalities. London: The Stationery Office 2009.

Department of Health. £13.5 million for areas with poor health. 19 November 2008. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=384686&NewsAreaID=2&NavigatedFromDepartment=False

Deparment of Health. Majority of Brits are happy and believe in a fair society. 6 November 2008. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=383405&NewsAreaID=2&NavigatedFromDepartment=False

Department of Health. Phil Hope launches more 'Pacesetters' to reduce health inequalities. 19 November 2008. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=384650&NewsAreaID=2&NavigatedFromDepartment=False

Reform formerly reported in

Progress towards health inequalities targets
Process Stages: Implementation, Evaluation, Change
Policies towards reducing health inequalities
Process Stages: Pilot

Author/s and/or contributors to this survey

Oliver, Adam

Suggested citation for this online article

Oliver, Adam. "Recent developments in health inequalities policy". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/uk/a13/5