Select Committee on Health Minutes of Evidence


   (Professor Sally Macintyre, OBE, is Director of the Medical Research Council's Social and Public Health Sciences Unit at the University of Glasgow. This Unit, which is co-funded by the Chief Scientist Office at the Scottish Executive Department of Health, studies social and environmental influences on health. Professor Macintyre chaired the Evaluation Group charged with assessing the strength of the evidence submitted to the Acheson Inquiry).

  1.  In Britain there is a large body of research evidence documenting and analysing inequalities in health; indeed Britain is at the forefront of research on inequalities in health. However, there has been less research on the effectiveness of interventions designed to reduce inequalities in health. One reason is the perceived difficulty in applying experimental methods to the evaluation of social or public health interventions.

  2.  In consequence, many of the recommendations made to the Acheson Inquiry1 were based less on sound evidence about the effectiveness of the proposed policies2, and more on inferences from epidemiological data abut their social and biological plausibility.

  3.  Although there have been marked improvements in the overall health of the population in the last few decades, the benefits have been experienced unequally; death rates have fallen faster among more privileged social groups.

  4.  Well-intentioned health promotion policies may actually increase, rather than decrease, inequalities in health3. More advantaged groups in society may find it easier, because of better access to resources such as time, finance and coping skills, to take up health promotion advice (eg to give up smoking, improve diet) and preventive services (eg dental check ups and cervical screening). There is also some evidence that poorer sections of society may receive less benefit from lifestyle change or access to services (because their health may already be compromised by other factors).

  5.  Thus two public health goals, to improve population health and to reduce health inequalities, may sometimes conflict. Targeting health promotion efforts at the already disadvantaged may produce aggregate health gain at relatively little cost, whereas targeting the disadvantaged may produce less aggregate health gain and at greater cost.

  6.  Interventions to reduce inequalities in health (eg steep social class gradients in childhood traffic accidents) can be directed at one or more of three levels:

    —  the structural or regulatory level (eg increasing petrol tax, speed restrictions in urban areas);

    —  the local level (eg traffic calming schemes, the employment of road crossing attendants);

    —  individuals or families (eg school based training in road safety).

  7.  There is some evidence that targeting the first two levels may be more effective in reducing inequalities in health than targeting the last4.

  8.  The Acheson Inquiry's recommendations were not costed, and in some cases described desired goals (eg the development of high-quality public transport system, or a reduction in fear of crime and violence) rather than the specific means to achieve these goals.

  9.  The Government's response to the Acheson Inquiry5 described planned inputs, such as proposed investment in public transport, education and policing.

  10.  The missing linked between the Acheson Inquiry's description of desirable outputs, and the Government's planned inputs, is robust evidence about the connections between inputs and outputs, ie the effectiveness and cost effectiveness of specific strategies to reduce inequalities in health. It is thus difficult for policy makers to assess what is likely to work, and to work best.

  11.  The Government should implement the Acheson Inquiry's recommendation that all policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities. Public and private sector policies, programmes and projects should be monitored to assess their effects not only on population health but also on inequalities in health (since, as noted above, improvements in population health need not lead to reductions in inequalities in health).

  12.  The Acheson Inquiry recommended that a high priority should be given to the health of families with children. In terms of outcomes such as coronary heart disease mortality, the effectiveness of interventions targeted at mothers and children may not be observable for 50 or 60 years. However changes in inequalities in exposures to risk (eg inadequate diet, poor housing) and in intermediate health outcomes (eg birth weight, patterns of growth in childhood, educational achievement) should be detectable over a much shorter time scale.

  13.  Public health and health promotion practitioners are often reluctant to subject their policies, practices and projects to the sort of robust examination now required in evidence based medicine. Given that such policies, practices and projects involve considerable costs (financial, staffing time and opportunity costs) and could be ineffective or harmful, it is as important to evaluate these as it is to evaluate new drug or surgical therapies6.

  14.  Rather than assuming that no rigorous research on effectiveness can be conducted, because randomised controlled trials are difficult to conduct in the fields of social and public health policy, we should be creative in our approach to evaluating impacts on health inequalities. Important tools include:

    —  Systematic reviews of the impact of policies and interventions in the UK and elsewhere6,7.

    —  Capitalising on naturally occurring opportunities for comparative or before-and-after studies (eg the impact of fluoridation8,9).

    —  When scarce resources can only be directed towards a limited set of places or people, randomising those who do or do not receive them and/or phasing their introduction, to allow systematic evaluation of their effects (eg if funds are available only for 10 HAZs or Healthy Living Centres, choose not the 10 poorest areas to receive them, but the poorest 20, and then randomise them to intervention and comparison arms of a study).

  15.  Research should move on from documenting and analysing inequalities in health to the rigorous testing of strategies to reduce inequalities in health, taking a broad view of the determinants of health and of health inequalities.


  1.  Gordon D, Shaw M, Dorling D, Davey Smith G, editors. Inequalities in health. The evidence presented to the Independent Inquiry into Inequalities in Health. Bristol: The Policy Press, 1999.
  2.  Macintyre S, Chalmers I, Horton R, Smith R. Trying to use evidence to make policy: a case study. BMJ in press.
  3.  Macintyre S. Modernising the NHS: Prevention and the reduction of health inequalities. BMJ 2000; 320 (May): 1399-1400.
  4.  NHS Centre for Reviews and Dissemination. Preventing unintentional injuries in children and young people. Effective Health Care 1996;2(5)1-16.
  5.  Department of Health. Reducing Health Inequalities: An Action Report. London: Department of Health, 1999.
  6.  Macintyre S, Petticrew M. Good intentions and received wisdom are not enough. Journal of Epidemiology and Community Health 2000;54(11):802-803.
  7.  Zoritch B, Roberts I, Oakley A. Day care for pre-school (Cochrane Review). Oxford: Update Software, 1999.
  8.  McDonagh M, Whiting P, Wilson P, Sutton A, Chetnutt I, Copper J, et al. Systematic review of water fluoridation. BMJ 2000;321(7October):855-859.
  9.  NHS Centre for Reviews and Dissemination. A systematic review of public water fluroidation. York: NHS Centre for Reviews and Dissemination, University of York, 2000.

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