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Background
Health inequalities have been recorded since long before the funding
of the NHS and are known to have widened in recent decades. However,
it is recognised that the NHS has neglected its role in seeking
equity and that equity should be a more explicit priority in the
future. This is now part of the government's policy for the NHS.
However, there
remains a lack of clarity about the definitions of equity and the
policy mechanisms to achieve them. Two main reasons explain this.
First, stakeholders may have different views of equity and inequality
reflecting three axes: geographical (different areas), sectoral
(or organisational) and interest group (managerial, professional
and lay interests). Second, stakeholders may have multiple objectives;
there may be trade-offs between equity and efficiency, and also
between the desirability and feasibility of policy goals. Both reasons
will be significant given the current policy emphasis on partnership
across agencies.
Aims and
Objectives
The aims of this study are to undertake an empirical analysis of
the policy process in the NHS, in order to:
- examine how
policy towards health inequalities is formulated and implemented;
- examine how
and why national policy towards health inequalities becomes translated
'vertically' into local policy;
- examine how
and why local policy towards health inequalities differs 'horizontally'
between and within health authorities and other agencies;
- determine
which concepts and operational definitions of equity inform these
processes;
- determine
how these initiatives to tackle health inequalities are evaluated
at local levels;
- establish
whether examples of 'good practice' can be detected so as to inform
evidence-based policy making.
Study Design
The study consists of three inter-linked stages. The first is a
review of legislation and national policy documents, which will
be analysed to determine whether NHS policy goals display criteria
of equity which are explicit or implicit, diverse and ambiguous.
The second stage involves sending a short questionnaire to over
2000 named individuals in all Health Authorities, Community Health
Councils, NHS Trusts and Local Authorities in England, Wales and
Scotland. The questionnaire is largely 'closed' and consists of
tick-boxes, rankings and likert scales. It will ascertain the role
and importance of equality in the policy process through analysis
of geographical, sectoral and interest group differences. The final
stage is based on case-studies which will examine the policy process
in three diverse areas, consisting of an urban, suburban and rural
site. Individual and organisational meanings and motivations will
be assessed through analysis of local policy documents, in-depth
interviews with key stakeholders and observation of meetings. The
three stages will provide a balance between qualitative and quantitative
data sources in assessing the interaction between stakeholders in
formulating and implementing equity policies.
Policy Implications
If 'what counts is what works', we do not yet know what policies
have the potential to reduce health inequalities. The study will
contribute to knowledge of the policy process by assessing the appropriateness
and validity of models of policy formulation and implementation.
It will attempt to bridge the divide between academics, policy makers
and practitioners at all levels by an active engagement with policy
stakeholders, particularly through dissemination directed initially
to the case-studies sites and by the involvement of an advisory
panel of all the above groups.
Project Summary
The UK's new public health strategies have made tackling health
inequalities a major policy commitment at both national and local
levels. The project focused on the process of policy implementation
in 1999. It examined how the commitment to tackle health inequalities
was being implemented: vertically, as policy passes from central
government to local agencies, and horizontally, as it is interpreted
and applied within local organisations. The study was carried out
before the launch of national health inequalities targets in February
2001 and the decision to remove the regional tier of health authorities,
announced in May 2001.
The project
involved a documentary review of official reports, a survey of named
individuals in all health and local authorities, NHS Trusts and
Community Health Trusts in England, Scotland and Wales, and in-depth
case-studies of three health authorities and their partnership networks.
The survey achieved a low response rate overall (12%). Evidence
suggested that, rather than being completed by the named individuals
(as planned), questionnaires were passed on to the perceived 'relevant'
individual (e.g. the Director of Public Health). It thus appeared
that tackling health inequalities was not seen as 'everyone's business'
but largely the remit of public health. Because of the low response
rate, the findings below are those emerging from or confirmed by
the three case studies.
Key findings
- With respect
to the vertical implementation of policy, local practitioners
welcomed the national emphasis on health inequalities and felt
that national policy legitimated local initiatives. However, for
those who had long been tackling health inequalities, there was
concern that existing local strategies were simply being 're-branded'
to meet the new national priority.
- A major barrier
to the vertical implementation of health inequality policy was
the number of competing national priorities, like reducing waiting
lists, for which accountability was clearer and monitoring of
outcomes was more rigorous. For example, targets for waiting lists
were seen as 'hard targets' while tackling health inequalities
was seen as a 'soft target'.
- Horizontal
implementation was supported by local enthusiasm for health inequality
policy and much effort was directed into inter-agency partnerships.
Health inequalities policy tended to become the province of 'policy
entrepreneurs', leaving it vulnerable to their departure and to
competing pressures for management time. Budget deficits and the
variable character of local partnerships were additional barriers
to implementation. The constant threat of reorganisation and new
priorities also diminished enthusiasm for health inequalities
initiatives.
- The term
'health inequalities' and its public health focus can be
inimical to developing wider ownership of health inequality policy,
especially in non-healthcare agencies. However, among health service
agencies, including NHS Trusts and Primary Care Groups, health
inequalities was often seen as a minor responsibility. Nonetheless,
there are innovative examples where tackling health inequalities
was prioritised and barriers to policy development overcome, including
joint appointments, joint strategy/partnership groups and the
development of joint performance indicators.
- There was
a willingness to evaluate the impact of local strategies to tackle
health inequalities. However, while policy impacts were recognised
to need long time frames (of at least 5 years), the organisations
delivering them were assessed annually. Process measures (such
as the structure and composition of partnerships) therefore predominated.
This suggests that mechanisms of performance assessment for health
inequalities should be given higher priority.
- These findings
suggest that the policy, process and resource streams which underpin
the implementation of strategies to tackle health inequalities
do not always flow together. Policies laying down desirable objectives
are not consistently matched by processes and resources to translate
them into feasible outcomes. For example, the timescales over
which policy impacts are measured can conflict with those set
for organisational and individual performance management. Further,
lack of data-sharing between local agencies hinders the development
of evaluative systems which, in turn, are not well integrated
into decision-making processes.
- The findings
also underline the challenge of achieving 'joined up policy making'.
While the government emphasises the importance of a shared agenda
for public health, the range of sites in which policy is being
formulated and implemented can work against partnership between
local and national agencies. At national level, the sites generating
policies to tackle health inequalities include the Social Exclusion
Unit (run by the Cabinet Office), the Department of Health and
the NHS Executive. At local level, they include health authorities,
NHS Trusts, local authorities, community and voluntary organisations
as well as the independent sector.
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