The Association of Directors of Public Health (ADPH) has been in existence for over 150 years. The aim of the ADPH is to support all Directors of Public Health (DsPH) across the UK in improving and protecting the health of the population by working to:

—  collate and present the views of DsPH on public health policy to national governments, the media and other organisations;

—  influence legislation and policy at a local, regional, national and international level;

—  facilitate a support network for DsPH to share ideas and good practice and support problem-solving;

—  identify and fulfil the development needs of DsPH where practicable and appropriate;

—  in collaboration with others, further the development of comprehensive, equitable public health policies through relevant statutory and other bodies.

THE CONTRIBUTION OF THE NHS TO REDUCING HEALTH INEQUALITIES

Executive Summary

  The ADPH very much welcomes this inquiry. The dogged persistence of health inequalities is one of the greatest challenges facing government and the NHS today.

  The difficulty in addressing health inequalities is because provision of services often results in disproportionate take-up from the relatively less deprived thus increasing inequalities. The obvious answer is to target services to those most in need but this can be politically unpopular. In addition targeting must be very well defined using population segmenting techniques such as social marketing if it is to be successful in closing the gap.

  There are some services (eg smoking cessation) that are cost-effective and when targeted appropriately are showing progress against inequalities but stronger evaluation and extension of successful programmes should be more strongly supported.

  GP services and practice-based commissioning need to be incentivised to address health inequalities and include preventive measures as a matter of course.

  Many national and local policies (including from the NHS and Department of Health) are not "proofed" for health inequalities before implementation and some have inadvertently caused an increase in health inequalities.

  Throughout our response the ADPH has considered health inequalities as a population issue ie inequity defined by health need. This is not the same as the "post-code lottery" which is unequal access to services based on geography. Addressing the former will improve the health of the population whereas addressing the latter helps individuals.

DETAILED RESPONSE

1.   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.

  1.1.  ADPH recognises that the NHS is neither the sole nor major agent in reducing health inequalities. The prime drivers of health inequalities in the UK are income, social and educational inequalities. However, the NHS can contribute to a reduction in health inequalities in a number of ways.

  1.1.1.  The systematic application of equity audits to ensure that health service provision and use is equitably distributed across the population.

  1.1.2.  The development, funding and scale up of targeted interventions which specifically support the health and well-being of disadvantaged communities and individuals with a specific focus on delivery of universal high quality primary care eg CVD prevention, care and treatment.

  1.1.3.  Participation in local and national schemes which aim to improve inequality in income or educational attainment (examples include Warm Front initiative, local efforts to improve benefit uptake, Healthy Schools Standard).

  1.1.4.  Taking its responsibility as a major employer seriously by ensuring it has the right incentives in place to address inequalities and encourage healthy living for its staff.

  1.1.5.  Health inequality impact assessments should be usual practice on all NHS policies before implementation.

2.   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.

  2.1.  The distribution of GP services is relatively fixed but the NHS has an opportunity to direct marginal resource to areas of greatest health need. Using measures such as under-doctored areas, although not definitive (since delivery of primary care is by multi-disciplinary teams), can provide a guide. It is important to have the highest quality primary care in the areas with the greatest health need, which tends not to be the case at present. More targeted use of Public Health / School nurses to address eg sexual health, teenage pregnancy, obesity issues etc would also support addressing inequalities.

  2.2.  One major inequality issue in Primary Care is that some of the most disadvantaged people may not even be registered with a GP or may change practices often and fall outside the system.

  2.3.  The quality and outcome framework (QOF) has been a relatively weak tool in terms of improving quality in primary care but could have greater impact with more public health incentives, particularly those where the reduction of inequalities is a clear target. Disease registers and brief interventions for lifestyle change re smoking, alcohol and obesity, screening and immunisation programmes should be included. Even where incentives exist eg re CVD prevention there are still major inequalities between practices.

  2.4.  Practice-based commissioning would have greater impact if it placed more emphasis on encouraging practices to improve the quality of the primary care they deliver rather than achieving marginal improvements in the delivery of secondary care. More emphasis on complete pathways including preventative measures would support work against health inequalities.

  2.5.  Practice-based commissioning should be required to show they are working towards addressing population needs (including addressing inequalities) as well as improving quality and making better use of resources.

3.   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.

  3.1.  There is good evidence that some successful preventive interventions (eg smoking cessation) are cost-effective and have the potential to reduce health inequalities. However, these do not yet have sufficient reach. A priority should be to ensure these services are scaled up and targeted appropriately. In other areas (eg obesity) services are not yet being delivered in a way which is sufficiently evidence-based and comprehensive in delivery to make a significant impact on broad health outcomes.

  3.2.  It is likely that public health interventions which are inequitably delivered may be contributing to a widening of health inequalities (examples include some smoking cessation services, screening programmes, alcohol treatment services). This is most often due to the tendency of the least deprived to garner resources and to gain the greatest benefit from services.

  3.3.  Even targeted services, particularly when area-based can widen health inequalities because of this tendency. The ability (and not just the opportunity) for the most disadvantaged to access services is critical and more needs to be done to understand approaches to increase this. The use of social marketing techniques has the ability to support this (examples include the smoking cessation work in Knowsley, Derbyshire and Nottingham).

  3.4.  Targeting services costs more and there are disincentives in number-based national targets (eg counting the number of smoking quitters rather than who they are).

  3.5.  Some very disadvantaged groups (eg migrant workers, travellers, prisoners etc) are not considered in policy-making and require highly targeted services.

  3.6.  Initiatives relying heavily on health promotion approaches without full consideration of market segmentation (eg social marketing methodology) are often cited as increasing inequalities because information is more accessible and acted upon more readily by the more affluent and better educated.

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

  4.1.  Specific community-based interventions such as those cited have been demonstrated to lead to significant health benefits for those who access the services. As with Sure Start they need to be evidence-based and locally driven. However, as mentioned above, any area-based initiatives will tend to benefit those who are relatively less in need (see for instance the national evaluation of Sure Start).

  4.2.  It is increasingly clear that further attention will need to be given to targeting the resources available through and improving access to such programmes so that the most economically deprived individuals and groups can benefit from the programmes.

  4.3.  In part the difficulty in providing evidence of benefits relates to the time-scales needed for such programmes to demonstrate tangible results. The balance between being seen to achieve quick wins and gaining longer-term benefits often leans to the former whilst tackling health inequalities requires an emphasis on the latter.

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

  5.1.  There are myriad examples of the NHS contributing to inter-sectoral and inter-organisational initiatives aimed at reducing health inequalities. However, initiatives are generally poorly evaluated, sustainability is often overlooked, and opportunities to identify with and scale up successful initiatives are not grasped.

  5.2.  The moves towards increasing co-terminosity and joint Director of Public health appointments is supporting joint working and the DPH is well-placed to lead on health inequalities. There are many examples where this is working very well. However, this relies on a well-resourced team working across sectors. Local Area Agreements are major drivers with joint commissioning the main tool. At District level, the good work achieved before recent PCT restructuring must not be lost despite fewer DPH posts.

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

  6.1.  Inequalities are a multi-faceted problem and require a multi-pronged attack from different organisations working in partnership. The collaboration between agencies often works well locally but would be further enhanced by stronger national co-ordination between government departments to ensure national drivers and incentives for different organisations provide synergy at a local level.

  6.2.  The ADPH believes that the lead for cross-sectoral work on inequality should often come not from the Department for Health but from the Treasury since the greatest drivers for and barriers to the reduction in inequalities are economic. This would also support the robust financial and strategic planning required to realise the benefits of the Wanless report recommendations.

  6.3.  There are examples of notable success in cross government working. These include the recent progress on smoking legislation, seatbelt legislation, etc. ADPH believes that future government policy should be informed by these successes and that fears of public abreaction against government intervention in public health policy are largely unfounded and can be effectively managed. Possible areas for future cross government action which would have significant impact on health status and reduce health inequalities include: pricing and availability of alcohol and food labelling.

  6.4.  Tobacco is still the main contributor to the gap in life expectancy between rich and poor. The recent proposals re graphic warnings on cigarette packets and sale of tobacco from vending machines are welcomed. Additional legislative protection should be considered to provide proper protection for children from secondhand smoke. The ready availability of cheap smuggled and counterfeit tobacco in the most deprived communities makes quitting smoking more difficult. Cross government action is needed to tackle this effectively.

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

  7.1.  Targets will not be reached unless there is both local work and national incentives to drive progress. Government should be willing to acknowledge and accept its stewardship role in protecting and improving the public health even when this conflicts with powerful vested interests.

  7.2.  Current trends indicate that the infant mortality and life expectancy targets will not be met. The PSA targets are achievable but cannot be delivered through NHS-led health interventions alone. Continued efforts to reduce child poverty and improve educational attainment and a redirection of public policy towards reduction of income inequalities will be required for long-term progress against health inequality targets.

  7.3.  Continual re-structuring combined with the raiding of "Choosing Health" monies to fund NHS deficits has had a detrimental effect on public health programmes and delayed the achievement of targets in some areas. Public Health goals, particularly such intransigent ones as inequalities require a long time-line and consistent work. The government should take this into account before considering further changes in NHS structures.

January 2008