Tackling Health Inequalities in the UK 1997-2010 – Evaluating the Acheson report
Summary by Don Nutbeam, Department of Health a Health Equity Network Seminar – notes published by the Nuffield Trust
Background and policy context
Soon after being elected in 1997 the Blair Government commissioned an Independent Inquiry into Inequalities in Health, chaired by the former Chief Medical Officer, Sir Donald Acheson. The Report of this inquiry was published in 1998. The Acheson Inquiry examined the determinants of health using the ‘layers of influence’ model first proposed by Dahlgren and Whitehead (1991). The Report made 39 recommendations and provided policy directions to tackle health inequalities. It recognised that tackling health inequalities would require actions to address all of the ‘layers of influence’, as well as ensuring that access and utilisation of health services improves among those who had previously been under-served. Two key policy papers have framed the government’s response to these challenges.
The Saving Lives – Our Healthier Nation White Paper was published in 1999 and set out a programme to save lives, promote healthier living and reduce inequality in health. It advocated co-operative effort across government to tackle the determinants of health inequalities, and recognised that sustainable action will come from government working in partnerships with local communities and individuals.
The NHS Plan was published in 2000 and provides a blueprint for the reform of the NHS. The Plan emphasised the importance of tackling health inequalities in a context of considerable extra public investment directed towards improving and modernising the National Health Service (NHS). It gives particular emphasis to reducing inequalities in access to NHS services, especially primary care, as well as emphasising the need to improve child health, and on a population basis, to improve nutrition and reduce smoking. Although primarily focussed on the NHS, The Plan overtly recognised the need for the NHS to work in partnership with other public services and agencies to tackle the underlying causes of ill-health and inequalities.
Targets to reduce health inequalities
The Government gave a commitment in The NHS Plan to establish national health inequalities targets which would narrow the gap in health status in childhood and throughout life, between socio-economic groups, and between different areas in the country. These were originally announced in February 2001, and are now included as part of the 2002 Spending Review Public Service Agreement (PSA) for the Department of Health in the following form:
By 2010 reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth.
These targets being in detail:
A. Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between routine and manual groups and the population as a whole.
B. Starting with local authorities, by 2010 to reduce by at least 10 per cent the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.
International comparisons indicate that there is substantial scope for improvement on both life expectancy and infant mortality. Both targets aim to narrow the gap between those with poor health status and the population as a whole, a gap that is generally widening. Achievement of the targets is not only about saving lives overall, but is about ensuring that a higher proportion of the gains are made by those in poorer circumstances. It focuses attention on the distribution of health benefit, rather than simply on overall health outcomes from the provision of programmes and services. Improvements in life expectancy will be achieved through a very wide range of actions.
The Saving Lives White Paper emphasised the need for action to tackle some of the well-established risks for the ‘big killers’ – cancer and coronary heart disease (CHD). This includes reducing smoking, improved diet and weight control, better detection and management of hypertension, effective screening services, and improved access to high quality treatment, alongside action directed at the determinants of health highlighted in the Acheson Report. Death rates for CHD and cancer in the UK remain unacceptably high overall and reflect substantial geographical, social class and ethnic group differences.
The purpose of the infant mortality target is to galvanise a wide range of actions to improve the health of mothers and their children. These include reducing teenage pregnancies, improving access to high quality ante-natal care, efforts to reduce smoking and improve nutrition during pregnancy and early childhood years, and effective early childhood support.
Action across government to reduce health inequalities
The ambitious targets set by the UK Government will only be met if all parts of government act in a coherent way to address the underlying determinants of health and health inequalities. Significant actions have already been taken across government in the past five years. These include:
Tackling poverty and low income: for example, by increasing the national minimum wage and by reforming tax credit and welfare payments. This has led to a redistribution of wealth that has raised the income of poorest families.
Improving educational and employment opportunities: for example, by substantial public investment in New Deal programmes to assist people into work (especially young people and the long-term unemployed), in school education, and in extending opportunities for lifelong learning.
Rebuilding local communities: for example, through the Strategy for Neighbourhood Renewal, and the promotion of local strategic partnerships between local government, non-government organisations and the NHS.
To better co-ordinate and further support action across the different government departments, the government established a Cross-Cutting Spending Review focussed on health inequalities. This presented a unique opportunity to provide coherence and direction to the range of government services and programmes that have the potential to reduce health inequalities. As the name implies, the review examined government spending across departments to consider the distribution of benefit to health of a range of government programmes in education, welfare, criminal justice, environment, transport and local government. The report from this review was used by these departments to inform their spending plans for the 2003-6 period, and will lead to binding commitments to take action as a part of a cross-government delivery plan to reduce health inequalities, due to be published late-Autumn 2002. The report grouped the findings of the review into five themes as follows:
Breaking the cycle of health inequalities – addressing poverty, especially in families with children, supporting a healthy pregnancy, and early childhood development (Sure Start), and educational interventions to close the attainment gap.
Tackling the major killers – addressing the social gradient in modifiable behavioural and physiological risks, and in treatment service provision.
Improving access to public services and facilities – addressing the inverse care and provision ‘law’, especially in relation to primary care, and public transport.
Strengthening disadvantaged communities – working ‘with the grain’ of neighbourhood renewal, and regeneration strategies – improving housing, creating a safe environment, engaging public services in employment and education.
Reaching vulnerable groups – working ‘with the grain’ of social exclusion strategies to address the needs of the ‘fuel poor’, the mentally ill, rough sleepers, and prisoners and their families.
Consultation on a plan for delivery
A further commitment from the NHS Plan was to consult on the wide range of actions that might be taken by government, communities and individuals to address the causes of health inequalities. In parallel with the cross-cutting review, the Department of Health conducted a public consultation through the document Tackling Health Inequalities. This focused on identifying working examples of successful programmes to tackle the causes and effects of health inequalities – to improve our understanding of how to take practical action in local communities to address the determinants of health and inequalities. The results of this consultation have recently been published.
Setting in place a system for delivery
A major focus for subsequent work is on developing systems and structures that will protect and support existing good practice, extend the reach and impact on health inequalities of existing programmes and services, and oversee the implementation of the future commitments that emerge from the cross-government delivery plan.
The delivery plan will be structured around the long-term targets (above) to reduce the gap in health status between social groups and geographical areas and will be published in late Autumn 2002. The Plan will be underpinned by short to medium term ‘milestones’ drawn from a cross-government ‘basket of indicators’. These milestones and indicators will be used to monitor progress, and will inform the future allocation of funding and assessment/management of performance in both the NHS, and in local government through Local Public Service Agreements (LPSAs).
Much progress has been made in getting the policies right, and aligned in a way that will produce a powerful cross-government effort to address health inequalities. The Acheson Report, the Saving Lives White Paper and The NHS Plan provide a substantial analysis of the problem, and provide the policy context for the response. The consultation on a plan for delivery provided information on front-line practitioner experience to add to this existing evidence. The cross-government spending review has sought to bring comprehensiveness and coherence – backed by resource commitments. The current finalisation of the delivery plan will specify what needs to be achieved, and who will be responsible for delivery.
Success is most likely with strategies that connect health care reforms with the wider set of UK public sector reforms and in doing so address the underlying determinants of health inequalities. Great attention will need to be given to sustaining current interest and commitment as we build capacity for effective action at the local level.