CRITICISMS OF THE TARGET
Should the target focus only on socio-economic
inequalities?
144. As we have discussed in Chapter 2, health inequalities
are evident across a number of different measures—not only
socio-economic status, but ethnicity, gender, age, disability
and regional area. This suggests that health inequalities should
perhaps be measured and targeted in a multidimensional way. There
is evidence that some PCTs are already doing this. Alwen Williams,
Chief Executive of Tower Hamlets PCT, told us:
For us, given our population, issues of ethnicity
are key. One of the challenges the NHS has is: how do we measure,
so we can measure the impact of what we are doing in relation
to the different population groups within our communities? We
have implemented, for example, patient profiling in our general
practices so that we are starting now to measure ethnicity in
a much more comprehensive way. That will help us ensure we can
then measure equity of access, equity of health outcomes in relation
to some of those factors that are part and parcel of our population
make-up. We are not doing that because that has been a target
set for us: that is because we understand that for us to be successful
in what we are trying to do around health improvement that is
a key component—for us to be able to understand and measure
our achievements and successes in future years.[112]
Should infant mortality be in the target
145. As mentioned above, we were told by the ONS
that as numbers of infant deaths are now so low, it is very difficult
to discriminate between areas in a statistically sound way, as
only a couple of random occurrences of infant deaths are needed
to invalidate this. This raises questions about whether infant
mortality is a valid way in which to measure health inequalities
and whether it should be included in the target.
Timeframe
146. Some witnesses told us that ten years was an
insufficient timeframe to achieve this level of change; Professor
Sir Michael Marmot, Professor of Epidemiology and Public Health
at University College London and Chairman of the Commission on
Social Determinants of Health, argued that a more realistic ambition
would be 'closing the health gap in a generation'.[113]
Inequalities or the health of the poorest?
147. As discussed previously, the trend of widening
health inequalities does not mean that the health of those in
the lowest socio-economic groups is getting worse. In fact, life
expectancy amongst the lowest socio-economic groups continues
to increase. Inequalities have worsened not because the health
of the poor is getting worse or even staying the same, but because
the rate of health gain is faster amongst more advantaged groups.
148. On visits to Norway and the Netherlands, we
heard that in having a target which explicitly aims to reduce
inequalities rather than simply improving the health of the poor,
England has one of the toughest targets in the world. It was suggested
that a better approach to improving health might be a focus on
improving the health of the most disadvantaged groups rather than
on narrowing differences. Professor Julian Le Grand, Chairman
of Health England, agreed:
One should focus on the absolute level of ill-health
of the poor. One of the pieces of advice I gave the Government
a very long time ago was that setting a target in health inequalities
is almost certainly a mistake, because almost certainly you will
miss it—and, indeed, that is exactly what has happened.[114]
149. Professor Ken Judge, Head of the School of Health
at the University of Bath, did not believe that the target has
provided sufficient focus in this area:
Certainly in England the view has been, and the pressure
from the public health lobby on the Government at the time was,
that the adoption of targets would help to focus efforts and drive
through change-agendas which deliver more progress. There is little
evidence that has been the case in the last seven or eight years,
I am afraid.[115]
150. Others, however, maintained that having an 'aspirational'
target such as this was instrumental in galvanising policy makers
towards targeting this area. The Healthcare Commission argue that
missing the target should not be viewed as failure, arguing that:
Without these targets, the situation would have been
worse. In combination with the health inequalities elements of
other related targets, the target has provided a focus for commissioners
and service providers and has driven improvement in several areas
including teenage pregnancy, infant health, tobacco control and
life expectancy. We therefore congratulate Government on setting
the target and establishing a Health Inequalities Unit. These
were brave decisions and gave a strong message, raising the profile
of health inequalities and adding to the debate.[116]
151. The Secretary of State was firm in his defence
of the adoption of such a difficult and possibly unrealistic target:
It would give us an easier life but I think it would
be depressingly unambitious just to say, "Let's target the
poor and forget about the inequality gap."[117]
Promoting short-term measures?
152. Concerns were voiced about the way in which
the target is measured, skewing efforts to tackle health inequalities.
Some witnesses argued that the targets, and indeed the measures
recommended by Government to achieve them, focusing predominantly
on treating CHD in the over-50s, might actually divert effort
and funding away from more long-term and potentially more valuable
interventions focused on preventing ill-health in today's children
and young people.[118]
On the other hand, it might be perverse not to treat CHD in the
over-50s since it is one of the few interventions which is known
to work.
Focus on the most deprived or other groups
153. The target focuses on improving the health of
the most deprived section of the population relative to the population
average, but inequalities occur across the whole of the population;
the higher an individual's socio-economic group, the better his
or her life expectancy. A case can be made for setting a target
which raises all other socio-economic groups relative to the highest.
This may be more cost-effective as middling socio-economic groups
might be more receptive to a range of policy instruments.
Neglecting local inequalities?
154. Efforts to meet the national target, which compares
average rates for the whole PCT against national averages, may
also mask inequalities that exist within deprived PCTs, as well
as neglecting pockets of deprivation that exist in more affluent
PCTs. Alwen Williams, Chief Executive of Tower Hamlets PCT told
us:
We can do the comparison of Tower Hamlets versus
other PCTS in our Spearhead group over the rest of the country,
but actually if we look at men living in Bethnal Green and men
living in Millwall, there is a difference of eight years in terms
of life expectancy. There are some interesting statistics and
we are looking a bit more at this; but looking at Spitalfields,
which is predominantly a Bangladeshi community, the life expectancy
there for women is higher than the national average; so we have
actually got some unexpected statistics[119]
155. As the Healthcare Commission pointed out in
its written evidence, focusing on improvements in only the most
deprived areas would not address health inequalities fully, as
there were pockets of deprivation in all areas. The HCC, in its
recent review of PCTs' efforts to improve smoking cessation, found
that many PCTs, especially those in more affluent areas, were
not yet successfully targeting small areas or population groups
known to have high levels of smoking.[120]
We were also told that in a PCT it is actually very difficult
to deliver targets based on social class, as the data may not
exist, often locality (eg index of multiple deprivation) and/or
ethnicity are used as alternatives.
THE CROSS-CUTTING REVIEW
156. Since 2000, the Department has published a series
of action plans and reviews aimed at bolstering progress towards
the target. The Cross-Cutting review, led by the Treasury and
published in 2002, aimed to co-ordinate action across Government
departments. In response the Department of Health published Tackling
Health inequalities—a programme for action in 2003,
which set out a total of 82 indicators measuring factors which
would contribute to reducing health inequalities, underpinned
by 12 'headline' indicators against which progress would be systematically
reviewed.[121]
157. The Department of Health's progress report,
Tackling health inequalities—2007 status report on the programme
for action, which was published in March 2008, presents a positive
view, stating that of 82 departmental commitments to support the
national health inequalities strategy, 72 have now been met.[122]
Unfortunately, although the most of the 82 department commitments
have been met, health inequalities are widening, and of the 12
'headline' indicators, only a handful have demonstrated progress
in reducing inequalities between social classes. In some areas
inequalities have actually widened.
Progress against 12 national headline indicators[123]
