Select Committee on Health Minutes of Evidence



MEMORANDUM BY PROFESSOR MARGARET WHITEHEAD (PH 76)

1.  SIGNIFICANT DEVELOPMENTS IN PUBLIC HEALTH POLICY

  1.1  There have been many positive developments in public health policy-making in the last few years, in particular.

    —  It is now legitimate to talk about inequalities in health and to pose serious questions about how to tackle the problem in Britain, witness the setting up by the Government of the Independent Inquiry into Inequalities in Health in 1997-98 (the Acheson Inquiry). The Inquiry was a ground-breaking initiative for any Government to take, and has attracted international interest and influence.

    —  The appointment of the country's first Minister for Public Health, emphasising greater commitment to public health.

    —  The development of a national public health strategy, Saving Lives in 1999, that recognised the importance of the social determinants of health, not just health care. As the strategy emphasises, major causes of social inequalities in health in the UK include: poverty, social exclusion, poor working and living conditions. There has also been crucial recognition in Saving Lives and elsewhere that the solutions to inequalities in health lie in many sectors, not just health sector. Action to reduce inequalities, therefore, require partnership and joint working between sectors.

    —  Setting the reduction of inequalities in health as one of the two key aims of the national public health strategy.

    —  A switch in the White Paper, the NewNHS—modern and dependable, from the previous focus solely on technical efficiency to that of fairness and equity of access to services as priority objectives.

    —  The setting of the new overarching resource allocation objective for the NHS: "to contribute to a reduction in avoidable health inequalities". Again this is a world first. I know of no other national resource allocation effort that has gone so far towards a focus on public health, and the developments in the UK will be followed with great interest at an international level.

    —  This year's announcement in the NHS Plan that a national inequalities target would be developed in the next two years.

  1.2  These positive developments are tempered by a sense that the initial flush of enthusiasm to take the broader public health agenda forward may have cooled off in the past 12 months since the publication of Saving Lives. One sign of this cooling off is the muted consideration of public health in the NHS Plan (see section 2 below).

2.  SPECIFIC PUBLIC HEALTH IMPLICATIONS OF THE NHS PLAN

  This section gives some specific comments on the NHS Plan, as this important document was published after the first round of written evidence had been submitted to the House of Commons Inquiry.

  2.1  In several respects, the NHS Plan provides a great service to public health:

    —  It makes explicit the values that underpin such a crucial public service. It provides the most lucid and carefully thought-through statement yet of the NHS core principles (pages 3-5), including in the first—that health care is a basic human right.

    —  It uses a health systems approach to analyse alternative funding models against the twin tests of equity and efficiency (chapter 3).

    —  It promises the creation of national health inequalities targets (which were absent from the public health strategy Saving Lives).

  2.2  In some other respects, however, the NHS Plan appears to signal less enthusiasm/more ambiguity about public health and about addressing inequalities than previous policy documents such as the 1999 Saving Lives and the Government response to the Acheson Report. This can be seen in the following:

    —  Although one chapter (chapter 13) is devoted to "Improving health and reducing health inequalities" (and there are many excellent points in it), the issue does not seem to carry through very far into other key areas in the Plan. In Chapter 14, for example, which details clinical priorities, the Plan is silent on social, economic and environment determinants of the priority diseases.

    —  In general, the targets and performance indicators throughout the Plan are expressed as averages, with insufficient recognition of the need to monitor the distribution of outcomes across different social and ethnic population groups. The stated intentions in chapter 13 to address distributional issues will need to be integrated more fully with the developments in the rest of the Plan.

    —  Unlike other professional groups within the NHS, no special attention is paid to the need for capacity building for public health efforts (including epidemiological expertise and skills in inter-agency partnership working). The dangers of fragmentation of the workforce with public health skills, and the need to maintain a critical mass of expertise in strategic agencies at local and national level, are not explicitly recognised or discussed.

    —  Unlike the other agencies (such as NICE) charged with improving the evidence base for clinical treatment services, no specific resources are ear-marked for building up the evidence base on the effectiveness of health promotion and wider public health interventions. The Health Development Agency has a very small budget to investigate a potentially enormous field.

3.  WHAT COULD BE DONE TO IMPROVE THE SITUATION?

  There are four main areas/levers which would greatly enhance current efforts to reduce both inequalities in health status and in the experience of health care.

3.1  Strengthening leadership/commitment

  Strategically, it is very important for the Government to give clear and strong signals that public health efforts to tackle the social determinants of health and to reduce inequalities are of the highest priority. At the national level, such commitments would be made explicit by maintaining a high status for the Minister of Public Health, with the capacity to influence other Government departments, and developing an inspirational national target to reduce health inequalities. At the local level, the pivotal role of Directors of Public Health needs to be underlined by ensuring their independent voice, supported by properly resourced teams.

3.2  Building capacity and structures to facilitate public health working

  Much more attention needs to be given to building the capacity and skills base of the existing public health workforce, and to expanding the numbers and range of other professional groups involved in taking the inequalities agenda forward. In addition to expanding existing public health training schemes, this needs to involve an organisational development agenda for a population perspective in the newly emerging health and local authority agencies, such as PCGs and PCTs. Capacity building is also needed within the statutory sector in general to enhance capacity to work in partnership with local communities on health issues (along the lines of the current R&D project: the Strategic Action Programme for Healthy Communities, funded by the Department of Health). Above all, structures need to be developed to ensure a critical mass of people with epidemiological and other population perspective expertise in strategic agencies at local and national level.

3.3  Developing tools for monitoring and performance management with an equity focus

  More concerted efforts are required to help assess whether there are differences in impacts and outcomes of policies and interventions for different population groups in society. This applies to local, national and international policies that have the potential to influence the public health. In particular, people trying to implement and refine action to reduce inequalities in health need:

    —  Methodologies for health impact assessment and health inequalities impact assessment of policies/interventions that take distribution of effects into account;

    —  The formulation of operational targets that take distribution into account;

    —  Monitoring and performance indicators that do not just measure variation from the mean, but identify systematic differences between social and ethnic groups in access, uptake and outcome of care. These need to form part of performance frameworks across the full range of action for health (health promotion, protection, prevention, curative and palliative care).

3.4  Further development of policies and strategies that will make a difference to the lives of the worst off in society

  The three priority areas singled out by the Independent Inquiry into Inequalities in Health provide guidance on where the sustained effort should be focused. These are:

    —  "all policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities;

    —  a high priority should be given to the health of families with children;

    —  further steps should be taken to reduce income inequalities and improve the living standards of poor households," (Independent Inquiry into Inequalities in Health, 1998, page xi).

  The first point has already been discussed in 3.3 above. The second and third priorities need sustained policy development especially around the areas of:

    —  Further reducing income inequalities and improving the living standards of households in receipt of social security benefits by uprating of benefits and pensions according to principles which protect and improve the standard of living of those who depend on them and which narrow the gap between their standard of living and average living standards;

    —  Enhancing access to high quality, affordable childcare and social support for parents—extending the work of Sure Start;

    —  Developing family-friendly employment policies to allow parents who want to combine working with their caring roles to do so;

    —  Making environmental improvements, including reducing psychosocial stress levels in the workplace and the living environment;

    —  Developing more equitable resource allocation mechanisms, not only in health, but also in social and education sectors, to match resources more closely to need.


 
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