1.  EXECUTIVE SUMMARY

  1.1  NICE guidance helps to improve public health and make access to healthcare and opportunities to improve health more equal across the country. Our approach to health inequalities includes:

—  supporting and monitoring the implementation of NICE guidance so as to eliminate variations in access resulting from uneven uptake;

—  a particular focus on reducing health inequalities in our public health guidance; and

—  systems to ensure that, where it can, NICE guidance promotes equitable access to treatment, prevention and health promotion.

  1.2  As variations in implementation of NICE guidance have implications for equity, we support local implementation by providing a range of forward planning and costing tools and advice, and through a team of regional implementation consultants who talk directly to NHS trusts and local authorities.

  1.3  The healthcare standards are an important factor in promoting uptake of guidance. It is essential for NICE's role—and in the interests of a high quality, cost-effective health service with an effective role in reducing health inequalities—that new arrangements for healthcare regulation from April 2009 reinforce the importance of compliance with all categories of NICE guidance.

  1.4  NICE's public health guidance programme covers a range of health topics, risk factors, population groups, settings, and generic processes of potential importance in tackling health inequalities. It has revealed substantial gaps in evidence about cost effectiveness and the differential impact of interventions associated with factors such as social class, ethnicity, gender, age, and deprivation.

  1.5  In the course of developing guidance NICE makes research recommendations to fill evidence gaps. There are around 400 of these so far, including 39 public health research recommendations. It is important for NICE, the NHS and government health policy that there is a more rapid response to these research recommendations.

  1.6  Upcoming public health guidance on complex interventions will present research challenges going beyond the health sector. A strategic approach involving collaboration by the Department of Health with other government departments will be needed to fill gaps in the evidence base about multi-sectoral action to deal with public health problems.

  1.7  It is important for the work of NICE and the NHS in promoting equality that a concern for identifying the impact of interventions across the various dimensions of equality identified in the government's equalities review is integral to research and data-gathering activity within the national research and health information strategies.

  1.8  An annex to this memorandum prepared on behalf of the Public Health Interventions Advisory Committee (PHIAC), the advisory body responsible for producing NICE's public health intervention guidance, discusses important lessons from PHIAC's work that are relevant to several of the questions posed in the Committee's terms of reference.

2.  ABOUT NICE

  2.1  The National Institute for Health and Clinical Excellence (NICE) is the organisation responsible for providing national guidance, and setting standards, on the promotion of good health and the prevention and treatment of ill health.

  2.2  NICE produces guidance in four areas of health:

—  public health—guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

—  health technologies—guidance on the use of new and existing medicines, treatments and procedures within the NHS

—  clinical practice—guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS

—  interventional procedures—guidance on whether procedures used for diagnosis or treatment are safe enough and work well enough for use in England, Wales and Scotland.

  2.3  NICE guidance helps to improve public health and make access to healthcare more equal across the country. Although the NHS is NICE's main audience, NICE guidance increasingly makes recommendations aimed at local government, providers of adult social care and children's services, and other public sector agencies.

3.  HEALTH INEQUALITIES AND NICE'S ROLE

  3.1  A commitment to reducing inequalities in access to healthcare and other opportunities to improve health is integral to NICE's role of providing national guidance. Our approach to health inequalities has the following elements, which are discussed in more detail in the next sections:

—  Support for NHS organisations in implementing NICE guidance, and systems to monitor progress in eliminating variations in access to services resulting from uneven uptake locally;

—  A particular focus on reducing health inequalities in NICE's public health guidance;

—  Systems to ensure that, as far as possible, NICE guidance promotes equality—in relation to race, disability, sex, sexual orientation, religion or belief, and age—in access to care and opportunities for improving health, as well as helping tackle health inequalities associated with socioeconomic status.

  3.2  The annex to this memorandum has been prepared on behalf of the Public Health Interventions Advisory Committee (PHIAC), the advisory body responsible for producing NICE's public health intervention guidance. It discusses important lessons from PHIAC's work that are relevant to several of the questions posed in the Committee's terms of reference.

  3.3  Progress in tackling health inequalities depends to an important degree on the scale and quality of the public health evidence base. Much of our submission is a discussion of the continuing weakness of the public health evidence base and why urgency in the public health research effort is vital for NICE's work and for the general effort to tackle health inequalities.

4  ELIMINATING VARIATIONS IN IMPLEMENTATION OF NICE GUIDANCE

  4.1  There is uneven implementation of NICE guidance, even though a direction on funding makes local provision of treatments recommended in technology appraisals more or less mandatory, and the healthcare standards include expectations of adherence to NICE clinical guidelines and public health guidance.

  4.2  An Audit Commission study identified weaknesses in local financial management as the most significant barrier to implementation (Audit Commission 2005).[267] However, the reasons for delay in uptake need further investigation and we are currently investigating the part played by a range of factors, including, for example, the level of deprivation in PCT areas.

  4.3  Provision in a PCT area of treatments or services recommended by NICE guidance does not of course guarantee that everyone who might benefit from an intervention gains access to it or takes it up. However, the persistence of variations in uptake does have implications for equity, and so we have significantly expanded our support for local implementation in the last couple of years. We now provide a range of tools and searchable databases, which can all be found on our website. These are designed to enable NHS trusts to include implementation of NICE guidance in their forward planning, manage the financial implications, monitor progress on implementation, share experience of implementation, and, as appropriate, commission evidence-based care. We also have a small team of regional implementation consultants whose job is to provide a more tailored service of support, advice and problem solving to the local NHS and local authorities.

  4.4  The current healthcare standards require healthcare organisations to comply with NICE guidance: technology appraisals and guidance on interventional procedures in the case of the core standards; and clinical guidelines and public health guidance in the case of developmental standards. This, in conjunction with the role of the Healthcare Commission, is an important factor in promoting uptake. The decision to create a new health and social care regulator from April 2009 and related changes to the NHS's performance management framework mean that there will shortly be a reconsideration of the role and form of healthcare standards and nature of regulation. We suggest to the committee that it is essential for NICE's role—and in the interests of a high quality, cost-effective health service with an effective role in reducing health inequalities—that new arrangements reinforce the importance of compliance with all categories of NICE guidance.

5.  NICE GUIDANCE AND HEALTH INEQUALITIES

  5.1  A concern with equitable access to treatment and care is central to all NICE guidance, but, as envisaged in the 2004 Choosing health white paper, NICE's public health guidance has a particular focus on improving population health and well-being and narrowing health inequalities.

  5.2  Our public health guidance falls into two categories: public health intervention guidance, which makes recommendations on relatively simple, often face-to-face, interventions that help to reduce people's risk of developing a disease or condition or help to promote or maintain a healthy lifestyle; and public health programme guidance dealing with broader and generally more complex interventions aimed at promoting good health and preventing ill health in the population, and narrowing health inequalities.

  5.3  So far we have published six items of intervention guidance. These cover smoking cessation, smoking cessation in the workplace, physical activity, sexually transmitted infections and teenage conceptions, substance misuse, and school-based alcohol interventions. A further nine items of guidance are in development. These cover various dimensions of mental health and well-being, smoking by children, needle exchange, immunisation, and improving access to services in disadvantaged areas.

  5.4  We have published programme guidance on behaviour change, and a further 11 topics are in development, covering, for example, various aspects of child health, the health of children in care, the management in the workplace of long-term sickness and absence, and smoking and physical activity.

  5.5  In addition, we published in 2006 a clinical guideline on the prevention and treatment of obesity. This was jointly developed by the former National Institute for Clinical Excellence and Health Development Agency (HDA), and covers a very wide spectrum of clinical and public health interventions.

  5.6  All NICE guidance includes an analysis of gaps in the evidence. In the case of public health, these gaps are invariably substantial and confirm the continuing validity of the Wanless report's findings on the dearth of evidence about the cost effectiveness of public health interventions (Wanless 2004).[268] They also highlight the lack of topic-specific evidence on the differential impact of interventions associated with factors such as social class, ethnicity, scale of deprivation or disadvantage, and other factors.

  5.7  For example, in the case of smoking, the NICE guidance on brief advice to encourage smoking cessation identified a lack of evidence on the effectiveness of the intervention in relation to age, gender, socioeconomic status and ethnicity. Our obesity guidance found little evidence on the effectiveness of multi-component interventions among key at-risk groups (such as young children and families and black and minority ethnic groups), vulnerable groups (such as looked-after children and young people, lower income groups and people with disabilities) and people at vulnerable life stages (such as women during and after pregnancy and people stopping smoking). This guidance also recommended that future research should collect sufficient data to assess how the effectiveness of the intervention varies by age, gender, ethnic, religious and/or social group.

  5.8  Our guidance on the generic principles of behaviour change—applicable to the problems of smoking and obesity as to all other public health risk factors—found that evidence about cost effectiveness was lacking, particularly in relation to sub-groups in the population such as 19-30 year-olds, low-income groups and particular ethnic and disadvantaged groups. It also stated that few studies of behaviour change interventions addressed the comparative effect on health inequalities, particularly in relation to cultural differences.

  5.9  Despite limitations in the evidence, our public health guidance has been able in most cases to recommend interventions for both effectiveness and cost effectiveness. In the case of the latter, and where sufficient data for modelling purposes has been available, the estimated incremental costs of a QALY gained have been within a range well below the NICE acceptability threshold of £20,000-£30,000.

  5.10  We recognise that, by stimulating the use of new or improved treatments and services, NICE guidance may result in a widening of the social class health gap as a result of better initial uptake by the people in higher social class groups, who tend to be better informed and adept at navigating the healthcare system. Local implementation strategies geared to ensuring as far as possible equitable access for those whom the intervention is intended to benefit are key in counteracting this effect. Policy developments on commissioning for health and well-being, including the recent Department of Health guidance on joint strategic needs assessment by PCTs and local authorities, are important in this regard.

  5.11  As already noted, evidence about effectiveness in reducing health inequalities for specific public health interventions is frequently lacking. However, where appropriate we integrate into our recommendations evidence about generic processes likely to help in tailoring interventions and targeting them at disadvantaged groups and other sub-groups in the population—for example, partnership working among agencies, rigorous needs assessment, consultation with and participation by recipients of the intervention, monitoring of impact, and evaluation.

  5.12  We are in addition producing guidance about particular generic processes of this kind. This guidance is intended for use in conjunction with guidance on specific risk factors, population groups, and settings as a means of achieving a sharper focus on health inequalities. Examples of this are forthcoming guidance on community engagement and on improving access to services in disadvantaged areas through proactive case-finding and retention. The former will build on known associations between community development approaches and health improvement; and the purpose of the latter is to increase statin use and uptake of smoking cessation in disadvantaged areas, thus contributing to reductions in premature death from cardiovascular disease and lung cancer.

6.  FILLING THE EVIDENCE GAPS

  6.1  One of NICE's functions is that of identifying clinical and public health research priorities arising from evidence gaps identified in the process of developing guidance and promoting them to research funding bodies. Each piece of NICE guidance therefore includes recommendations for research considered to be important in informing the next review of the guidance (usually after a period of three to four years).

  6.2  These research recommendations are of strategic importance in that they emerge from a uniquely robust and systematic sifting process; they relate by definition to the priorities of the NHS because they have arisen from clinical and public health topics that have been referred to NICE in the first place; and they are intimately connected to the NHS reform objective of achieving value for money through cost-effective treatment, care and public health practice.

  6.3  Research recommendations from 2004 onwards are freely available to all parties interested in health research on the NICE website. As of June 2007 there were 384 recommendations arising from all categories of guidance. Although NICE took on responsibilities for public health relatively recently, there are already 39 public health research recommendations (including those in the obesity guidance).

  6.4  We have welcomed changes in the organisation and focus of health research following the Department of Health's Best research for best health strategy (DH 2006)[269] and the Cooksey review (Cooksey 2006),[270] including greater involvement of NICE in research governance arrangements. We also have a "direct access" arrangement with the National Institute for Health Research's Health Technology Assessment (HTA) programme for taking forward a small number of agreed "essential" research priorities. Nonetheless, competing demands for research funds mean that as yet few NICE research recommendations have resulted in commissioned research projects.

  6.5  This indicates that, despite some progress in raising the profile of public health research, much more remains to be done, particularly given the government's ambitions to reduce health inequalities, raise the level of spending on prevention and health promotion nearer to the OECD average, as pledged in the 2006 white paper, Our health, our care, our say, and get the NHS on a trajectory towards Wanless's "fully engaged scenario". In this context it is worth reminding ourselves of the baseline position: the UK Clinical Research Collaboration's analysis of UK health research spending found that only 2.5% of research spending was on prevention of disease and conditions and promotion of well-being (UKCRC 2006).[271] We suggest to the Committee that it is important both for NICE and the NHS that the research infrastructure responds rapidly to NICE's research recommendations.

  6.6  A further research challenge will become apparent over the coming months and years as the volume of NICE public health programme guidance increases. This guidance will often be about complex, multi-sectoral interventions aimed at public, private and voluntary sector agencies, including but going beyond the NHS—for example, encompassing the various local agencies involved in local strategic partnerships (LSPs). Consequently, evidence gaps and related research recommendations will cover policy fields outside the conventional remit of healthcare research.

  6.7  Some of these research recommendations will be about the need to evaluate policies and programmes aimed at changing features of the broader social, economic and physical environment that conditions the health behaviour and choices of individuals, families and communities.

  6.8  We suggest to the Committee that there is a need for a strategic approach involving collaboration by the Department of Health with other government departments in developing joint programmes to fill gaps in the evidence base about multi-sectoral action to deal with public health problems. The most obvious lead-partners would be the Department for Communities and Local Government (DCLG) and the Department for Children, Schools and Families (DCSF), but with the involvement as appropriate of the Department of Transport, the Home Office and others.

  6.9  Finally, as already noted, NICE guidance identifies gaps in evidence about the impact of interventions on sub-groups in the population, such as people from black and minority ethnic groups or people in different age groups. This is generally because of failures to investigate such impacts in clinical trials and other evaluations. It also identifies gaps in data from surveys and routine information collection in the NHS and elsewhere in the public sector about the distribution among population sub-groups of health and ill health, risk factors, use of and access to services, and of the impacts of clinical and public health interventions.

  6.10  The government's Equalities Review (Equalities Review Panel 2007)[272] found that health inequalities data were not collected for the purpose of understanding the impact on group inequalities, and there was no continuous and systematic recording or analysis of ethnicity, disability, sexual orientation or religion or belief. In response to the review, the Office for National Statistics carried out a review of equality data and has made over 20 recommendations directed at itself and other government bodies with the aim improving the accessibility and presentation of data across the range of equality characteristics (National Statistics 2007).[273]

  6.11  NICE is committed to promoting equality and eliminating discrimination in relation to race, disability, sex, sexual orientation, religion or belief, and age through its guidance. Furthermore, the operating framework for 2008-09 has made promoting equality a priority for the NHS. We suggest to the Committee that it is important for NICE's work on health inequalities and for frontline organisations that a concern for identifying the impact of interventions across the various dimensions of equality is integral to research and data-gathering activity within the national research and health information strategies.

NICE

January 2008

1.  INTRODUCTION

  1.1  PHIAC is the independent public health advisory committee of NICE which deals with NICE's public health intervention guidance. Membership is multi-disciplinary, comprising professionals and practitioners (specialists and generalists), representatives of the public, community groups and technical experts drawn from the NHS, local government, universities, the voluntary sector and the general public. It meets once a month and has been in existence since November 2005. Much of its work has been concerned with activities in the NHS. There are a number of important lessons from the work of PHIAC which will be of relevance to the Select Committee.

  1.2  The nature of its work means that PHIAC has considered a vast amount of evidence on the effectiveness and cost effectiveness of public health interventions across a wide range of topics. We therefore believe that we are well placed to provide to the Select Committee a balanced view on the extent to which evidence based guidance to the NHS is possible, how it is likely to influence the NHS's capacity to contribute to the reduction of inequalities, and how this capacity might be enhanced in the future.

  1.3  PHIAC's role is to consider and interpret evidence on the effectiveness and cost effectiveness of all public health interventions. It formulates recommendations to NICE on their use in the NHS, local government and the broader public health arena in England. It has a particular interest in reducing health inequalities and considering the impact of interventions on the pattern of health inequalities. At the centre of its concern is the familiar public health conundrum. This is that in Britain we have experienced decades of overall health improvement at population level, but at the same time the health inequalities gradient has remained constant or got worse. The reason for this is that in a developed country like Britain universal services (such as the National Health Service) do not have universal effects. Universal services have differential effects, with the better off benefiting disproportionately. The factors which lead to general health improvement—improvements in the environment, good sanitation and clean water, better nutrition, good health service provision, high levels of immunization, good housing—do not necessarily reduce health inequity. This is because the determinants of good health are not necessarily the same as the determinants of inequities in health (Graham & Kelly, 2004). In order for the inequalities gradient to shift in a more equitable direction, the ways in which interventions can be targeted and universal systems made more usable for the relatively disadvantaged, and the ways in which different sectors in the population respond to interventions needs to be central to the research, policy and planning processes. PHIAC attempts to take these factors into account in its deliberations.

2.   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government

  2.1  PHIAC recognizes the critical importance of so-called "upstream" influences such as income, education, employment and the material environment in generating and maintaining inequalities in health. Nonetheless it considers that the evidence shows that the NHS has a role to play, both in delivery of its own services and by working in partnerships in others. In the public health guidance produced by NICE we have sought to make evidence based, cost effective guidance on how the NHS might do this in specific areas. However, the NHS is not currently compelled to implement this guidance. The Select Committee might consider recommending that the public health guidance issued by NICE must be implemented in the NHS.

3.   The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities

  3.1  PHIAC recognizes the potential importance of primary care in reducing inequalities in health. Much of our guidance to date has related to primary care. We have noted that the incentives systems currently in use do not specifically reward those who work to reduce inequalities in health and in some cases may lead to increases in inequalities. We believe that there is potential for incentives schemes, which have a generic evidence base of effectiveness, to be better focused on reduction of inequalities.

4.   The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective

  4.1  The assessment of effectiveness and cost-effectiveness of public health interventions is the central task of PHIAC. We are concerned that, as a general rule, the introduction of health promotion measures, particularly those based on information giving or requiring active participation by the public, may lead to increases rather than decreases in inequalities. We have tried to take this in to account in developing our guidance.

5.   Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective

  5.1  We welcome the evaluations of these, where they have been done. However, we note that, in many cases, they were introduced in a way that precluded rigorous evaluation, even though alternative methods of introduction would have allowed evaluation without delaying introduction. In addition we note that many of these interventions would not be expected to be effective or cost effective for a considerable period. Furthermore, assessment of cost effectiveness needs to take all relevant costs and savings into account.

  5.2  We recommend that more rigorous methods of evaluation accompany innovations such as these.

6.   The success of NHS organizations at co-ordinating activities with other organizations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organizations improve care

  6.1  PHIAC is aware of examples of good practice in areas of the country but believes that there is undesirable inconsistency which is likely to increase inequalities in health. We consider that partnership working is an important element of NHS work and have made a number of evidence based recommendations in our guidance to this effect.

7.   The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meets its Public Service Agreement targets for reducing inequalities; and

8.   Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities

  8.1  PHIAC has not conducted a review of the targets, but we wish to make a more general observation. The evidence we have considered in different topics indicates that, regardless of the targets, health inequalities are deeply ingrained in our society. We consider that evidence based public health guidance can make an important contribution to service implementation to address health inequalities and to national and local policymaking which directs and supports service implementation.

9.   Development of the evidence base

  9.1  We have been struck by the limited evidence base which is directly applicable to the UK and so to the NHS. The lack of evidence in public health in general is even graver when considering inequalities in health. Much of the evidence we consider is from other countries, particularly the US. The lack of progress on tackling inequalities in health reflects in part a lack of knowledge on how they may be altered. If inequalities in health are to be tackled effectively it is essential for the evidence base to be developed. This will require a concerted and sustained effort from funders, researchers and practitioners.

  9.2  Much evidence could be obtained at relatively little cost by improved data collection and analysis within the NHS and with its partners. In addition, a requirement to evaluate new interventions introduced in the NHS, including a requirement to assess their effect on inequalities in health (ie their differential effectiveness and cost effectiveness) would allow the evidence base to be developed whilst not paralyzing innovation.

10.   Using the existing evidence base

  10.1  We consider that the existing evidence base is under-used, partly because of an inappropriate emphasis on particular types of research, such as clinical trials. Our experience at PHIAC has been that a wide variety of research and information can inform service development. What is lacking is the capacity and sometimes the will to develop the use of this information to inform local and national decision-making. We recommend that this capacity is further developed at national and local level.

11.  CONCLUSION

  11.1  As noted above, PHIAC considers that, despite the challenges of the evidence base and the need to strengthen it, there is potential to make evidence based recommendations to the NHS on the reduction of inequalities in a range of areas. PHIAC is pleased to be contributing to this work but believes that the resources devoted to this are currently grossly insufficient and are limiting what the NHS can achieve.

REFERENCE

  Graham, H & Kelly, M P (2004) Health inequalities: concepts, frameworks and policy. London: Health Development Agency. http://www.nice.org.uk/page.aspx?o=502453

268   Wanless D (2004) Securing good health for the whole population. London: HM Treasury.www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm Back

269   Department of Health (2006) Best research for best health-a new national health research strategy. London: Department of Health.www.dh.gov.uk/en/PolicyAndGuidance/ResearchAndDevelopment/ResearchAndDevelopmentStrategy/DH_4127109 Back

270   Cooksey D (2006) A review of UK health research funding. London: HM Treasury.www.hm-treasury.gov.uk/independent_reviews/cooksey_review/cookseyreview_index.cfm Back

271   UKCRC (2006) UK health research analysis. London: UK Clinical Research Collaboration.www.ukcrc.org/publications/reports.aspx Back

272   Equalities Review Panel (2007) Fairness and freedom: the final report of the Equalities Review. London: The Cabinet Office. http://archive.cabinetoffice.gov.uk/equalitiesreview/ Back

273   National Statistics (2007) Review of equality data. London: Office for National Statistics.www.statistics.gov.uk/about/data/measuring-equality/default.asp Back