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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