INTRODUCTION

  This paper is a response by the National Consumer Council (NCC) and National Social Marketing Centre (NSM Centre) to the Health Select Committee Health Inequalities Inquiry. The NSM Centre is based at the National Consumer Council and was established in 2006 to increase understanding and use of effective social marketing approaches at national and local level across the public sector and to work across sectors to build evidence based approaches to behavioral challenges. It is led by Director, Dr Jeff French and Deputy Director, Clive Blair-Stevens. The centre has a number of core staff and a wider number of social marketing associates that contribute to different areas and is assisted by input from the Department of Health and the National Consumer Council.

EXECUTIVE SUMMARY

  We do not believe the government is likely to meet its targets on health inequalities without a significant re-focusing of effort, as set out in this submission. In particular, we would wish to emphasise:

—  Action requires a systematic and sustained policy and delivery framework with adequate funding and clear role definition across the broader policy agenda [Q1]

—  The development of insight based interventions, with clear behavioural goals, and a clear target population, needs to be incentivised [Q2,Q4], with a move away from the current block budgets funding mechanisms currently utilised

—  There is a current skills and capacity deficit within the workforce, which needs to be addressed to ensure that interventions are developed which reflect customer understanding and systematic application of social marketing best practice [Q3]

—  Investment is needed to build delivery partnerships, sharing user and customer intelligence, and building systems for capturing learning [Q5]

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  Effective action on health inequalities requires a systematic and sustained policy and delivery framework with adequate funding and clear role definition across the broader policy agenda, recognising that a singular focus on the NHS will not tackle the broader determinants of health inequalities.

  1.2  There is a need to distinguish between the Department of Health's role and that of the wider NHS. There are distinct contributions that the DH and the Wider NHS can make to tackling health inequalities but as yet this potential is largely untapped, or misdirected and of a wholly insufficient scale.

  1.3  The DH and the NHS must also develop new skills in working with the private sector to address the issues of health inequalities.

  The DH roles include:

  1.4  Advocacy and leadership including through practical action in purchasing and contractual arrangements and in leveraging change across the broader policy and delivery environments. However this function it is not currently resourced to a level that it can have a significant impact across government and across the private and third sector.

  1.5  Acting as a lead agency across government to begin a strategic dialogue leading to joint action between government departments and the private sector to tackle health inequalities.

  1.6  Setting targets and the operating framework for the NHS. Action in these areas focuses attention on health inequalities, stimulating action and engaging support in sectors outside public health. Targets need to be more open and transparent, with greater clarity about who is being targeted. Recent policy has tended to target the manual occupation groups rather than the most deprived. This has widened the gap for health inequalities by exacerbating the absolute gap between the most deprived and the rest of the population.

  The NHS roles:

  1.7  Delivery within its own sphere of influence, to ensure its services are customer driven and informed by insight, with better segmentation of its audiences reflected in delivery of more tailored interventions across the life-course.

  1.8  Greater investment is needed in developing skills within the NHS staff and the wider policy environment to engage with the broad social make up of disadvantaged populations, and to conduct research which can be translated into service provision which is both fit for purpose and welcomed by the target groups. This means the wholesale adoption of a systematic social marketing approach to understanding target audiences and developing services tailored to their needs.

  1.9  Ensuring future service provision is informed by insight, with effective segmentation used to design, deliver and evaluate services. One of the possible consequences of this approach would be to restrict access to the service to the identified target group, thus reducing the potential for exacerbating the gap.

  1.10  Moving away from short term and special project funding for community development programmes, health promotion programmes, working more closely with communities themselves to develop and deliver programmes which are locally appropriate and relevant with clear, measurable, short, medium and long term behavioural goals. However there is an absolute imperative to end poorly focused and poorly evaluated health promotion and community development interventions that have been the hall mark of much recent practice. The disciplines of a systematic social marketing approach need to be built into the inception and funding specifications of all future programmes if we are to attain the position of being able to more accurately assess the impact and return on investment of any future investment in tackling health inequalities.

  1.11  Modeling and developing sustainable, insight informed, services. There is significant potential for re-orientation of existing services, for example community pharmacy, to include a broader outreach dimension to promote health in local communities. More effective cross organisational partnerships, such as that exemplified by the work between Knowsley PCT and Roy Castle's FagEnds, should be supported to develop and deliver effective, targeted, locally relevant services.

  1.12  Mobilisation of wider partnerships and greater sharing of information and evaluation of what does and does not work to reduce health inequalities. The NHS could play a key leadership role in this process.

  1.13  More targeted use of its huge organisational footprint. The NHS is the largest employer, the largest purchaser, the largest commissioner and provider of training in many areas. A strategy should be developed to harness this power to tackle one of the root issues of health inequality, meaningful employment and sense of self worth.

  1.14  More support for community health action The NHS can and should as part of its core operating strategy aim to provide paid and volunteering opportunities on a much larger scale than hitherto.

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

  2.1  Access to primary care can be a significant health inequalities issue. However, focusing solely on GP services may be counterproductive to the long term aim, with a wider conceptualisation of primary care services required to address health inequalities.

  2.2  For some groups, especially marginalised groups, accident and emergency services are the point of entry into the health system. Rather than castigate these groups for inappropriate usage of services, there is a need to invest in research which considers why different groups see such services as their preferred point of entry, and look at how this can inform service design, commissioning and evaluation of service provision.

  2.3  Existing data sources could be used more effectively to target health inequalities, through identification of people with known risk factors, ie smoking, for targeted interventions, eg smoking cessation services. This process could be incentivised through the QoF.

  2.4  Research to date has identified that generic campaigns are less effective than interventions which are developed based on insight developed through research with defined target populations. Current funding structures, which generally favor short term projects deliverable within a financial year, militate against the development of such projects. Frameworks could be developed and used to incentivise more detailed scoping of projects, to address this shortfall.

  2.5  Current DH programmes, which treat health inequalities as a cross cutting theme, have been effective in mainstreaming the recognition of health inequalities into all policy and programme areas, including the QoF and PBC frameworks. This approach should be extended across government to achieve maximum impact.

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  Targeting key behavioural challenges, such as smoking and obesity, can be effective at reducing health inequalities. However, the evidence to date suggests that existing service models are potentially increasing the health inequalities gradient. This should not be regarded as a reason to forgo population based health reforms. Legislation and regulation, such as the smoke-free legislation, has had some impact, but needs to be seen as part of a spectrum of health promoting initiatives, not as an end goal.

  3.2  There are strong links between motivation, environment, health behaviours and inequalities, with causal links between Health Behaviours (eg smoking & over consumption of food) coping mechanisms and deeply engrained Social Norms and Motivation.

  3.3  Gaining deep insight and understanding into the consumer, their knowledge, attitudes and beliefs is essential to ensure that public health services are effective at reducing inequalities.

  3.4  There is a need for a fundamental review of workforce and the skills that they will need to tackle health inequalities across all public sector organisations. We have in essence been fighting the new war with weapons developed to tackle the battles of long ago. The skill set and competencies needed for talking behavioural, societal and managerial issues that sit at the heart of tackling health inequalities, whilst complementary to existing practice, are fundamentally different, and sustained effort is required to upskill and resource the workforce to reflect this

  3.5  Many of the models of public health promotion used to date are best characterised as message and information driven campaign models. Whilst raising awareness is valuable, these campaigns are often not proving effective at motivating behavioural change. Good customer focused and researched social marketing is helping to break the default position of communicating messages to people as the primary way to influence behaviour. NHS London and SHAs in Yorkshire and Humber, The North East and The North West are all leading the implementation of social marketing principles in the development of future public health inequalities interventions. The work being carried out by these SHAs should be supported and spread to all NHS organisations.

  Cost Effectiveness:

  3.6  A recent study of the use of economic analysis in NHS decision making[231] reports that respondents felt that economic evaluation was poorly understood and unrealistic in relation to NHS funding. These problems, compounded by the political and cross-sector nature of PHI, make it difficult to establish a clear process for taking decisions on public health investment. A review of public health decision making in eight countries[232] concluded "none had explicit systematic procedures for making decisions affecting public health or setting priorities among different public health interventions". This report also notes that remarkable few public health interventions are subject to systematic evaluation, particularly in the field of primary prevention measures such as behaviour change.

  3.7  There are two major challenges in the economic appraisal of Public Health Interventions; one is the difficulty of associating specific interventions with positive behavioural impacts and eventual health-related outcomes, and the second lies in the valuation of health-related outcomes. The latest and most comprehensive review of the evidence of the effectiveness of public health interventions in achieving behaviour change, by the NICE Behaviour Change Programme Development Group[233] shows that while there are a great many studies in this field there are few that use consistent methods of analysis.

  3.8  We would suggest there is a need for a systematic economic and evidence-based gap analysis to determine the most cost-effective funding level and intervention mix. Such a gap analysis should be used to develop decision tools for policy-makers and practitioners about how to best allocate resources to improve population health and tackle health inequalities. However, the development of decision aids will not produce foolproof algorithms that will remove the responsibility for judgment, but rather inform future decisions about investment and disinvestment.

  3.9  The allocation of large block budgets in advance of the development of detailed social marketing plans is, in our view, a mistake. This approach to budgeting and resource allocation creates a culture of working to spend the budget allocated in the year it is allocated rather than the development of proposals to meet agreed targets and then costing these plans and seeking budgets to deliver them.

  3.10  The current fixed-term block allocation system used by the DH to allocate funds to health promotion programmes and campaigns should be reviewed. There is a strong case for moving to a system of "mission-driven budgeting". Mission-driven budgeting, means only allocating budgets once a sound scoping phase and development phase of planning has been completed and convincing proposals have been developed that set out how budgets can be deployed to achieve desired outcomes.

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  Evaluation carried out by Sure Start and Health Action Zones and the Cabinet office review of Area Based Initiatives demonstrates that the interventions, in their current form, have had at best a negligible impact on reducing health inequalities. In some cases it appears they have had a negative impact on reducing inequalities. The experience of the Spearhead Programme has yet to be assessed, but it seems unlikely that it will yield significantly different findings.

  4.2  This depressing outcome reflects two specific deficits in the models used: the lack of specific, clear, actionable and measurable behavioural goals set by the projects at outset, and the failure to build the project based on informed insight, derived from scoping and qualitative research, into what would work with the target group. These failings would be addressed through the systematic application of social marketing principles and best practice.

  4.3  Social marketing is at its core a systematic planning system driven by user or target group insight. Social marketing draws on commercial marketing techniques and principles as well as the social sciences and behavioural research to develop insight based interventions to promote positive behaviours. It is not just a health promotion strategy, as it can be applied to any behavioural challenge, nor is it a re-badging of old style campaign models of health promotion or health communication.

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  Targets and the operating framework for the NHS have been crucial in focusing attention on health inequalities, stimulating action and engaging support in sectors outside public health. However, there is still a significant potential for mobilisation of wider partnerships, and greater sharing of information and evaluation of what does and does not work to reduce health inequalities.

  5.2  Increasing co-terminosity of the NHS structures with local government is laudable. However, without effective sharing of best practice, information sharing, and the development of more collaborative working practices, at best this will have limited impact on the health inequalities gradient.

  5.3  Investment is needed in building delivery partnerships, sharing user and customer intelligence and building systems for capturing learning across sectoral boundaries to tackle the underlying risk conditions faced by poorer people.

  5.4  A key task as indicated above is to more meaningfully engage the private sector in tackling health inequalities. The Business in the Community model is a good example of a practice approach that could be extended. We would also recommend the use of the WHO developed health assets mapping methodology that seeks to identify and mobilise all the positive assets in communities from across the public private and third sectors to address community identified problems such as health inequalities.

  5.5  Local Authorities and other public sector originations also have a huge role to play in using their organisational footprints to provide employment and training to those in most need. Local Authorities however like the NHS are not geared up to taking a segmented customer driven approach to tackling health inequalities.

6.   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

  6.1  Across DH there are many examples of work which is being delivered successfully across government departments, eg health literacy. Such programmes can have a tangible impact on health inequalities.

  6.2  We would strongly encourage the connection of health inequalities to wider agendas, both across government and within the field.

  6.3  However, the translation of policy commitment into field ownership has not always been effective, reducing the impact of such policies.

  6.4  The key issue is the scale of investment required to place health inequalities at the heart of delivery across government. The DH is well placed to lead this work but it needs to significantly up it game. The appointment of Dr Fiona Adshead as the new senior advisor for health inequalities and health determinants is to be welcomed as this would appear to signal the kind of step change in focus that is needed. The DH need to invest more and incentivise the NHS to invest more in taking on an active leadership role. We would suggest the establishment of a DH controlled but cross government funded innovations fund for health inequalities. Such a fund should be used to capture and spread good practice and build alliances nationally and locally across all sectors and agencies.

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

  7.1  Evidence to date suggests that the ability of the health services to reach the most effected communities is inconsistent.

  7.2  We believe that the government is unlikely to meet its targets without sustained effort and a re focusing of effort as set out in this submission.

January 2008

232   Allin, S. Mossialos, E. McKee, M. Holland,W. "Making decisions on public health: a review of eight countries" World Health Organisation Copenhagen 2004 www.euro.who.int/document/E84884.pdf Back

233   NICE Behaviour Change Group, "Behaviour Change, Synopsis of Evidence" December 2006 Londonhttp://www.nice.org.uk/page.aspx?o=395480 Back