The Healthcare Commission welcomes the focus being given to health inequalities by the Health Committee's New Inquiry.

  The Healthcare Commission was formed by the Health and Social Care (Community Health and Standards) Act 2003, and launched on April 1st 2004. Our role includes a duty to promote improvements in healthcare and we are the only regulator in the world with a statutory responsibility to assess healthcare organisations in relation to their public health delivery.

  In accordance with the terms of reference of the inquiry, our response is laid out under the published headings—points 1 to 7. We identify health inequalities in relation to population health outcomes. Public health is a key area in relation to health inequalities and we focus on this in a number of points. Inequalities in access and quality of care contribute to population health outcomes, and are included in our response where appropriate (for example, in point 2, GP services).

  In the first three years of the Healthcare Commission's existence, we have made considerable progress in ensuring that public health and particularly the tackling of health inequalities are central to our work and we continue to keep this focus. We have assessed all healthcare organisations on the standards for public health and the new and existing national targets, many of which address population health and health inequalities. We have produced regional reports on the results of these assessments and we would be pleased to share that information[285].

  We have conducted a number of improvement reviews, including one of all primary care trusts (PCTs) on tobacco control that fed into the annual health check ratings for the year 2005-2006 and resulted in a national report[286]. We have also conducted in-depth studies on sexual health[287], unintentional injury in the under 5s[288], childhood obesity[289], diabetes[290] and chronic obstructive pulmonary disease (COPD)[291] all areas where health inequalities are in evidence. Our annual State of Healthcare Report to Parliament has a focus on health inequalities.[292]

  It should be noted that a number of points raised in this submission come from recent work to be published in early spring 2008—Are we choosing health?, a review of the past ten years of policy and its impact on public health service delivery. We would be happy to provide a copy when it is published.

EXECUTIVE SUMMARY

  1.  Continued focus on health inequalities—for Government, local strategic partnerships, commissioners and providers: The Government should be congratulated on taking bold steps in setting standards and targets relating to health inequalities. However, the gap in health status between those people who are affluent and those for whom deprivation is a reality remains wide and shows little sign of narrowing. Efforts need to be maintained and expanded in the future.

  2.  Clearly the NHS cannot carry the entire burden of reducing health inequalities. NHS organisations must lead or support others to lead joined-up action across a local area to encourage the reduction of local health inequalities. The NHS does, however, hold several key roles in which it is able to contribute independently towards reducing health inequalities. These include both the commissioning and provision of programmes and services, improving staff health and contributing to the broader local economy in its role as the largest employer in England.

  3.  A more coherent approach across the public sector (and with the private and third sectors) is necessary to enable health, social care, housing, and education needs to be met and linked together for sustainable impact. Local area agreements should be focused to ensure a joined-up approach contributes to reducing health inequalities.

  4.  Role for regulation: Including public health and health inequalities in Standards for Better Health and within the Healthcare Commission's remit has had a positive impact across healthcare providers. Evidence from our assessments as well as our reviews and engagement with stakeholders suggests that provider trusts and PCTs have made considerable progress in developing work to tackle health inequalities as a result of the inclusion of public health and health inequalities within regulation.

  5.  Currently the Healthcare Commission assesses PCTs on how they invest and disinvest in services and programmes in relation to the needs of the whole local population, and particularly those with the greatest health needs. The Government's plans for a Joint Strategic Needs Assessment in each area will support PCTs to further develop this work with their partners.

  6.  We share strong concerns raised by public health professionals about the need to maintain and build on the progress that our assessment has provided. Currently the Bill setting up the new Health and Social Care Regulator does not include a remit to consider crucial areas of public health as part of registration requirements in provider trusts. Furthermore the future for the Standards for Better Health is very uncertain.

  7.  It is critical that public health is included within the remit of the new Health and Social Care Regulator, building on work to date by the Healthcare Commission and the Department of Health. This should link with regulation across sectors (such as Comprehensive Area Assessments as well as the role of Strategic Health Authorities in performance management) and cover both commissioning and provision of services.

  8.  Primary care provision: GPs need to be more involved in maintaining and improving patient health. We welcome the recent announcement by the Prime Minister on the introduction of health checks and an increase in screening opportunities to prevent illness. However, in order for these initiatives to impact positively on health inequalities it is important for plans to be in place to target those most in need—and to provide sensitive services for treatment and support.

  9.  There should be less variation across GP provision, particularly between single-handed and group practices. An effective incentive and resource framework is vital to make a difference to health inequalities and therefore the Quality and Outcomes Framework (QOF) needs to be revised to give sufficient incentives for health promotion and to ensure local government, PCTs and healthcare and local government organisations work together to provide joined-up wellbeing work. We suggest the new health and social care regulator has a role to complement and support the role of the PCT and SHA in improving standards in primary care.

  10.  Effectiveness: Further evidence of what works is needed for all health inequality issues. Currently there is good evidence for some areas, such as teenage pregnancy where both conventional research and innovative approaches to lesson learning have been used. This needs to be more systematically developed across topic areas. Obesity is an area where lack of information on children's weight has meant that tracking progress has been impossible, accountability at different levels (national, regional and local) is unclear, and targeting of programmes has therefore not been as effective as it should have been.

  11.  There is a need for better comparative information that shows whether local NHS and local authorities are making a difference (after taking account of differences in deprivation and demographics). Learning can take place by identifying key factors and approaches demonstrated by those areas performing better or worse than their peers.

  12.  Experience shows effective initiatives have usually benefited from some national capability for understanding, disseminating and developing best practice. NICE provides an important role in developing guidance and the Department of Health's national support teams give valuable support to those healthcare organisations most at risk of not delivering against national targets but in our view a proactive role with all healthcare organisations does not lie anywhere. There is a need for this explicit function at a national level to ensure that everyone performs at their best in delivering services and programmes to tackle health inequalities.

RESPONSE

Point 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

  13.  Undoubtedly the NHS cannot carry the entire burden of reducing health inequalities. It does, however, hold several key roles in which it is able to contribute towards reducing health inequalities. These include both the commissioning (purchasing) and provision of programmes and services. Also important are the health improvement opportunities that arise in the role of the NHS as the largest employer in England. In addition PCTs have a statutory responsibility to work with partners to improve health and reduce health inequalities within their local populations. (See point 5 of this response).

  14.  The requirement for the NHS to contribute to reducing health inequalities is currently set in statute. In Standards for Better Health (which applies to the provision of all NHS services across settings and which we assess as part of the annual health check), there is a requirement for each standard to be interpreted and implemented so as to challenge discrimination, promote equality of access and quality of services and support the provision of services appropriate to individual needs, preferences and choices.

  15.  The seventh domain of Standards for Better Health (C22 a & c and C23) contains specific elements to reduce health inequalities between different population groups and areas. Performance in this domain has already improved across all sectors in the two years the Healthcare Commission has carried out this assessment. In autumn of 2007, we conducted a survey of directors of public health. Findings were very positive and suggested that the inclusion of public health in the standards and regulation has already had a significant impact on raising and maintaining awareness, commitment and activity among both PCTs and provider trusts.

  16.  The considerable progress that PCTs and provider trusts have made in relation to health improvement was made even more evident to us through several events held by the Healthcare Commission. These included roundtables for senior national, regional and local professionals in public health and a successful series of large regional events for provider trusts to consider their progress in meeting the public health standards and to share good practice. Their examples demonstrated a growing commitment to public health and activities for tacking health inequalities as a result of our assessment. Among providers there was a commitment to systematically assess patients' needs for health promotion and health protection along their care pathways as well as a focus on staff health. Among PCTs there was evidence of linking local health needs assessment (including health inequality audit) to investment or disinvestment in commissioned programmes or services. We can provide these examples if requested.

  17.  We share the strong concerns raised by public health professionals about the need to maintain and build on the progress that our assessment has provided. Currently the Bill setting up the new Health and Social Care Regulator does not include a remit to consider crucial areas of public health as part of registration requirements and it is unclear how the new Health and Social care regulator will continue to assess improvement including how commissioning reflects local health needs. Unless this is rectified valuable ground in tackling health inequalities in the work of both provider trusts and PCTs will be lost.

  18.  At a time when obesity, unintentional injury, sexual health, alcohol, smoking and substance misuse (all with inequality dimensions) are national concerns, inequalities in life expectancy stubbornly persist, and the threat from climate change, avian flu and terrorist attacks remains ever-present (all also with an inequality dimension), The Department of Health may want to ensure that the regulatory levers that are clearly helping to deliver improvements in tackling these issues are maintained.

Point 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 might be used to improve the quality and distribution of GP services to reduce health inequalities

  19.  PCTs have a key function in ensuring GP—and wider primary care—services are appropriately situated and of high quality. As the front line of primary care, GP services are fundamental to public health in their role of addressing the primary risk factors of the highest causes of morbidity or mortality.

  20.  The Healthcare Commission has recently used QOF data to carry out analysis on diabetes and coronary heart disease (CHD), focusing on the association between deprivation and single-handed GPs. This analysis showed considerable variation in practice level performance.

  21.  Our work suggests that more deprived areas, while not under-doctored in relation to population size, are under-doctored in relation to the greater levels of need in deprived areas. Although in the past deprived areas were under-doctored, this appears to have been remedied by the introduction of salaried GPs. Taking coronary heart disease as an example, we found that practices with lower QOF scores for the management of blood pressure and cholesterol were more likely to be more deprived and to be single-handed than higher achieving practices. Single-handed practices were also significantly more likely to have higher non-elective admission rates for both CHD and diabetes, which suggests that early intervention is not available in those practices.

  22.  QOF is limited by the completeness of available data, as it can capture information only on people registered with a GP. For example, itinerant populations and newly arrived immigrants are rarely registered; anecdotally, in parts of London up to 25% of the population at any one time is not registered with a GP. This highlights the role for PCTs in ensuring that this is remedied.

  23.  To better contribute to reducing health inequalities, QOF data needs to be revised to give sufficient incentives for health promotion and to ensure PCTs, healthcare providers, local government and local government services provide joined-up health and wellbeing services. QOF reports should be made accessible to the public. Early access to services (health promotion, screening and treatment) and referral to hospital as appropriate should be the aim for all patients—particularly population groups known to access healthcare only in extreme circumstances—and should be the subject of incentivisation and performance assessment.

  24.  While PCTs should be encouraged to closely monitor QOF performance at practice level, QOF analysis alone cannot give a comprehensive assessment of the extent of care pathway inequalities. Therefore, monitoring of QOF performance should be carried out in conjunction with the monitoring of other related data sources, such as hospital episode in-patient and out-patient statistics and prescribing data.

Point 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

  25.  Almost half of PCTs scoring "excellent" in our review of tobacco control performance were from deprived areas. The delivery of high quality services in these areas is a positive step towards improving the health of those communities that traditionally carry a higher burden of disease and we were provided with several examples of good practice of targeting at risk groups within communitiesi. Historic investment was shown to contribute to continued improvement in performance. However, there are pockets of deprivation in all areas, and many PCTs, especially those in more affluent areas, were not yet successfully targeting small areas or population groups known to have high levels of smoking.

  26.  The model for tackling teenage pregnancy was considered by our group of experts to have been very positive and influential in the reversal of an upward trend in under 18 conceptions. The key components appear to be the development of a national strategy and national targets with a mandatory requirement for a locally agreed strategic plan and locally tailored targets; a national, regional and local infrastructure (staffing and performance management); and resources. Engagement at the highest ministerial level guaranteed the attention and involvement of decision makers. Successful aspects of this model should be considered for use in other programmes, such as obesity, although the current reduced role of central departments in providing direction could limit the effectiveness of this approach.

  27.  Other examples of effective public health services include NHS stop smoking services, although our assessments suggest worsening performance in this area, this is disappointing given the success of the smoke free public place legislation. Areas such as obesity, unintentional injury, mental health and older people have fared less well as described below.

  28.  Tackling overweight and obesity and related health inequalities should be a key element of the performance management framework for regional bodies. Our report on childhood obesity[293] made several recommendations for fundamental elements required to effectively tackle obesity. Departments should provide guidance on data collection as well as evidence about effective approaches, including targeted programmes. PCTs, local government and local services should be encouraged to provide joined-up services, including targeted, sensitive and effective programmes for those most at risk of overweight and obesity and support for people who are obese. All relevant programmes should be adapted to ensure that health inequalities in relation to obesity are taken into account, such as ensuring access to healthy foods and leisure facilities in deprived areas.

  29.  People with severe and enduring mental health conditions experience poorer health outcomes, with a high risk of, for example, obesity, diabetes and smoking. Some black and minority ethnic groups have higher rates of admission and detention in mental health hospitals than the average population and are more likely to be referred via the criminal justice system, yet they have lower rates of referral from primary care[294]. This does not necessarily reflect the health status of people from BME communities, but suggests a lack of provision and access to primary care and health service providers for people, such as refugees and asylum seekers, and Roma, Gypsies and travellers. This lack of provision and access should be addressed to prevent people from these communities accessing healthcare at a later point in the chain, when factors/symptoms have worsened and can be further compounded by issues such as associated crime or homelessness.

  30.  Older people face problems with access and quality of care in general, with access to GPs a particular problem. Data shows that older people in deprived areas have higher tooth loss, reduced access to essential but low-level foot care affecting mobility and wellbeing, inadequate access to intermediate and specialist mental health care and difficulties in accessing GPs at night and at weekends. Poor mobility and lack of access to appropriate transport further hinder the effective care of this group. Health services offered to older people from minority groups where they form a small proportion of a community are even less developed, and patients are forced to rely on relatives to share the burden of care.

  31.  NICE[295] have published a range of clinical guidelines and health intervention and programme guidance on clinical and public health issues and continue to develop guidance outlining effective methods of addressing health inequalities. Our assessment of the standards is designed to ensure organisations use evidence of effectiveness including NICE guidance. We remain concerned that as yet, public health is not included within the legal remit to assess registration requirements for all healthcare providers, and hope this decision will be reversed. In addition we would want to see broader public health delivery contained within the new standards to promote improvement in commissioning and provision.

  32.  Even with published guidance in some areas, a challenge faced in using public health interventions is the lack of evidence of effectiveness. This is widely recognised in the field of health improvement and was recently raised in a series of workshops we held in the summer of 2007. Participants felt that there was a general lack of evidence in relation to health improvement delivery, and that where research did exist it was often hard to interpret. On occasion, commissioners were reported to believe that "a lack of evidence about an intervention suggests that the intervention doesn't work" while in reality it simply indicates that its effects are not yet proven.

  33.  In order to improve effectiveness it is essential that data collection and analysis improve. This should include:

—  ethnicity in birth and death registration records to facilitate targeted programmes to contribute to addressing inequalities

—  occupational status of primary carer in birth registration records (to prevent the exclusion of sole registered children from classification of socio-economic status)

—  increased data at neighbourhood level

—  improvements to programme budgeting for use as a tool for tracking resources in health improvement programmes and services

—  datasets being in line with the Department of Health's 2007 guidance, Informing Healthier Choices: Information and Intelligence for Healthy Populations

  34.  Evidence shows that public health interventions can have the unintended consequence of increasing inequalities either as a result of a delivery or take-up differential between different socio-economic groups. Consequently, initiatives must be thoroughly "proofed" before implementation to ensure they will not exacerbate inequalities. An upstream focus is important to address those most at risk at an early stage, rather than attempting to change learned behaviours or conditions (for example, in relation to smoking and obesity). Government, Department of Health and the NHS need to work together to identify the future causes of morbidity and mortality in 25 plus years time and start to build and implement strategies to address those issues now.

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

  35.  In our tobacco control improvement review[296], we found evidence of a positive legacy from Health Action Zones and more recently the spearhead initiative. The additional funding and focus provided by these initiatives appeared to contribute to above average performance in these areas.

  36.  Regeneration monies were also used to great avail by many organisations. Participants at our recent workshops considered these initiatives key in developing and delivering local public health programmes. However, a note of caution was raised in relation to the sustainability of ring-fenced/time-limited funding streams, as frequently, those areas in receipt of additional funding became a lower priority for mainstream finance.

Point 5:   The success of NHS organisations at coordinating 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

  37.  Clearly, the NHS cannot address the issue of health inequalities single-handedly, (especially given the emphasis on mortality differentials in the targets rather than, for example, quality of life). NHS organisations must lead or support others to lead joined-up action across a local area to encourage the reduction of local health inequalities. We welcome Comprehensive Area Assessments (CAAs), Joint Strategic Needs Assessments (JSNAs) and Local Area Agreements (LAAs), although we have concern about how health priorities will be chosen locally, and to what extent health inequalities will be included.

  38.  We highlight the need for these models of joint working (CAAs, JSNAs, LAAs) to be complemented by in-depth regulation. Our recent survey of directors of public health shows how significant our assessment has been in driving forward partnership work. Our in-depth reviews and assessment of the public health developmental standard have revealed examples of good practice in working with local partners to achieve improvements in public health. A key characteristic of high performing PCTs in our tobacco control improvement review, for example, was their engagement in partnerships with local agencies such as councils, hospitals and prisons. In our report on child obesity we detail the role each of the delivery partners can play to strengthen the delivery chain.

  39.  Publication of comparative data can drive improvement, as such all regulators and auditors need to be able to access standardised information across sectors.

Point 6:   The effectiveness of the Department of Health in coordinating policy with other Government departments, in order to meets its Public Service Agreement targets for reducing inequalities

  40.  To meet the PSA for reducing health inequalities, the Department of Health needs not only to work with other Government departments, but also to ensure that there is co-ordination between sections of its own department. A focus solely on treatment and care and not disease prevention and health promotion will have limited impact on health inequalities. Improving health needs to go hand in hand with tackling health inequalities in order to achieve the Wanless "fully engaged" scenario.

  41.  Health inequalities are much broader than health; to address them effectively requires engagement across Government departments. For example, public health issues are rarely considered early in plans for regeneration, which often features licensed bars, thus adding to the potential for increased obesity and alcohol consumption. Transport plans also have the potential to influence public health for the better by encouraging use of sustainable public transport or bicycle/walking routes. We welcome wider Government PSAs with the potential to have a positive impact on the health of the public, such as the increase in provision of long-term housing supply and affordability and the agreement to improve children and young people's safety.

  42.  Obesity has to date lacked a coherent cross-Government strategy and the infrastructure and resources to deliver. That this target is jointly owned by two Departments is a positive, yet challenging development. At a national level, the Departments have to align priorities for child obesity with their other PSA targets, and a number of other departments, such as the Communities and Local Government, the Department for Transport and the Department for Culture, Media and Sport will need to make significant contributions to ensure delivery of the target. This joined-up working will need to be reflected at regional and local levels.

  43.  Over recent years, the Government and the Department of Health have undertaken several reorganisations, which have created opportunities for new approaches, but have also threatened delivery. Examples discussed in our workshops included Shifting the Balance of Power for PCTs, PCT reconfiguration and the creation of Children's Directorates in local authorities. Attempts to make PCTs coterminous with local authorities were welcomed in the long term, but the disruption caused has taken time to settle and has compromised relationships and mature partnership arrangements.

  44.  To date, while there have been sustained attempts in policy to improve health and tackle inequalities in health, some non-aligned priorities from Government departments have made achieving local coherence challenging. For example, public health experts participating in our recent series of roundtable discussions found that policy seeking to promote patient choice in services inhibited progress in promoting equity of access, potentially benefiting some people over others. Sex and relationship education within Personal, Social and Health Education (PSHE) training is not mandatory, which potentially conflicts with achievement of the teenage conception target.

  45.  Co-ordination among Government departments needs to go beyond policy, and address, for example, data collection.

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

  46.  Performance to date would suggest that current health inequality PSA targets will not be met. However, this should not be viewed as failure. We believe that without these targets, the situation would have been worse. In combination with the health inequalities elements of other related targets, the target has provided a focus for commissioners and service providers and has driven improvement in several areas including teenage pregnancy, infant health, tobacco control and life expectancy. We therefore congratulate Government on setting the target and establishing a Health Inequalities Unit. These were brave decisions and gave a strong message, raising the profile of health inequalities and adding to the debate.

  47.  The short term nature of the targets is, however, of concern, as it has tended to focus action on the mid-fifties plus age group. Increased mortality in this group has the most immediate effect on life expectancy tables. Longer term targets would have encouraged focus on health promotion and preventative action in younger people to enable them to live longer, healthier lives and potentially have a positive impact on NHS resources and services in the future.

Anna Walker

Chief Executive

Jude Williams

Head of Public Health

January 2008

286   No ifs, no buts: Improving services for tobacco control (2007). Back

287   Performing better? A focus on sexual health services in England (2007). Back

288   Better safe than sorry: Preventing unintentional injury to children (2007) (a joint report with the Audit Commission). Back

289   Tackling child obesity-first steps (2006) (a joint report with the Audit Commission and National Audit Office). Back

290   Managing diabetes: Improving services for people with diabetes (2007). Back

291   Clearing the air: a national study of chronic obstructive pulmonary disease (2006). Back

292   All reports are available on our website www.healthcarecommission.org.uk Back

293   Tackling child obesity-first steps (2006) (a joint report with the Audit Commission and National Audit Office). Back

294   Count Me In Census. Back

295   www.nice.org.uk/guidance. Back

296   Results of this review have been published at individual PCT level against a detailed framework on our website www.healthcarecommission.org.uk and a national report No ifs, no buts; improving services for tobacco control has been produced in electronic and hard copy format. Back