1.  THE ASSOCIATION OF PUBLIC HEALTH OBSERVATORIES (APHO)

  The LHO is one of a network of twelve Public Health Observatories (PHOs) that form APHO covering the United Kingdom and Ireland. APHO supports the PHOs in generating timely health intelligence to support decision-making at local, regional and national levels. We are part of the NHS family and work in partnership with practitioners, policy-makers and researchers on:

—  Monitoring health, healthcare and disease trends and highlight areas for action;

—  Identifying gaps in health information;

—  Advising on methods for health and health inequality impact assessments;

—  Drawing together information from different sources in new ways to improve health;

—  Carrying out projects to highlight particular health issues;

—  Evaluating progress by local agencies in improving health and reducing inequality; and

—  Looking ahead to give early warning of future public health problems.

  The London Health Observatory (LHO) is the national lead observatory on health inequalities, ethnicity and health and tobacco. For more information about the LHO and APHO see www.apho.org.uk and www.lho.nhs.uk.

2.  DEFINITION OF HEALTH INEQUALITIES

  Any assessment of the role of the NHS in reducing health inequalities needs to start with a clear definition of what is meant by health inequalities, and which inequalities we are aiming to reduce. As in pathways of patient care, there is a pathway of causation throughout which inequalities can be reduced. For the major preventable causes of untimely death and disability such as cardiovascular disease (CHD and stroke), cancers, accidents and injury, tackling the "upstream" causes such employment, income and educational inequalities determines the speed and success of further "downstream" action by the NHS and its local partners.

        Spectrum of inequality

Differences in Life Expectancy within a small area in London

  The above diagram illustrates the many types of inequality (from causes to outcomes) and the dimensions of inequality (age, gender, geography ethnicity etc) that could be addressed. The diagram below illustrates how geographical inequalities can be clearly defined, but does not define ethnic or other types of inequality.

3.  THE GOVERNMENT'S CURRENT OBJECTIVES TO REDUCE INEQUALITIES AND THE ROLE OF THE NHS

  The current, overarching cross-government PSA is defined in terms of reducing geographical inequalities in life expectancy within which reducing socioeconomic inequalities in infant mortality are a part. This has shifted the focus to "levelling up" the 70 "Spearhead Local authorities" and 62 Primary care trusts (PCTs) which are in the worst fifth of deprivation and health indices in England. The importance of having a clearly defined national target cannot be overemphasised. Prior to this there was no clarity, no focus and no means of monitoring national progress. However the NHS and its partners have a span of influence that is primarily local. Given the key role of central government in catalysing speedier local action, we recommend that local target-setting on health inequalities is left to local partnerships—primarily through the LAA process and that national targets continue to be set and monitored through national, evidence—based policy making. This would be in keeping with devolution and the current limitations on the evidence base.

4.  WILL THE GOVERNMENT MEET ITS CURRENT PSA TARGETS?

  Projections for 2010 at a national level have shown that inequalities in life expectancy are set to widen and inequalities in infant mortality showing some evidence of narrowinghttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081327

  The secretary of State for health has announced a review of the strategy for reducing health inequalities which will provide a timely opportunity for setting longer term objectives based on the evidence to date. Two learning points emerge:

—  The time needed to reduce inequalities in health outcomes is of the order of decades. It is thus vital to be able to identify both national and local evidence-based action in the short and medium term. It is the action that needs to be monitored alongside the outcomes.

—  Local Progress in tackling inequalities has been shown to be unequal too and we submit the example of the "London Health Inequalities Forecast"http://www.lho.org.uk/viewResource.aspx?id=11106

where inequalities in health are great and persistent. Only one spearhead authority/Primary care trust (PCT) in London is on track to meet the 2010 targets for life expectancy and cardiovascular disease and cancers. In the case of infant deaths, we submit our report "Born Equal?"http://www.lho.org.uk/viewResource.aspx?id=12371

showing that national targets are difficult to monitor locally but a focus on known effective interventions in maternity care can identify areas for action across ethnic as well as geographical dimensions.

  This evidence reinforces the need to separate what the NHS and partners can do locally out from what national government can achieve by population—wide legislation and fiscal policy.

5.  HOW CAN THE NHS MAKE A COST EFFECTIVE CONTRIBUTION TO REDUCING HEALTH INEQUALITIES?

  A local approach to cost-effective action needs to address the following questions:

 (i)   What are the causes of the Life expectancy gap in my Local authority/PCT?

  Whilst it is widely known that cardiovascular disease, cancers—mostly driven by smoking—explain the largest differences in the national gap in life expectancy, work by the Association of PHOs (APHO) has shown that the causes of the gap differ in different parts of the country. The London Health Observatory(LHO), and Yorkshire and Humber PHO(YHPHO) on behalf of APHO, have develop an easy to use, on-line "Health Inequalities Intervention Tool" that works out the size and causes of the gap in life expectancy for each Spearhead Authority. The diagram below shows the significant differences in the causes of the gap between Blackpool for example (where alcohol-related digestive causes are important) and Southwark (where infant mortality causes a major part of the gap). The tool can be accessed from the LHO website's home page (www.lho.nhs.uk)

 (ii)   Which interventions are cost—effective and what impact might they have on my local gap?

  The APHO online tool has a built-in interactive facility that helps users to plan the impact of four different, evidence-based interventions (smoking cessation, high blood pressure reduction and blood cholesterol reduction and infant mortality reduction) on closing the life expectancy gap.

  Given the need for all parts of the country to tackle inequalities within their local authority areas, APHO is now developing a sister inequalities intervention tool to help plan the impact of evidence based interventions between small areas within local authorities. This will be ready to use in Spring 2008. The focus for the tool has been on interventions where this is good evidence of cost-effectiveness in community/primary settings. Other evidence will be built on the future public health programme at NICE.

 (iii)   Use the commissioning cycle to shift or invest in preventive care where it is most needed

  World Class Commissioning expect the local NHS and local authorities to agree joint priorities through the Joint Strategic Needs Assessment Process and that inequalities where identified, can be prioritised. APHO is developing a an intelligence resource to support the JSNA process. The use of the new resource allocation formula and the pace of change agreed within it will have a major effect on the ability of the spearhead authorities to "catch up" with the England average. Given the limited local span of the NHS, the potentially most important opportunities for reducing the inequalities gap in a cost-effective manner lie within primary care prevention with individuals in the short term and joint work with the local authority and education partners with whole schools in the long term.

 (iv)   Monitor progress

  The PHOs work together to support local and regional agencies to monitor the implementation of policy. This work has been hampered by a serious lack of local authority-level data on key lifestyle issues. Current Local Data on smoking-the biggest proximal cause of health inequalities—along with diet and alcohol is not available for monitoring. It is unacceptable to expect the local NHS to rely on estimates alone. Local data on childhood height and weight has not yet been released to PHOs and is long overdue.

  We recommend that PHOs rapidly are designated as the main regional, safe repository of data on lifestyle as it is collected.

6.  THE IMPACT OF PRACTICE-BASED COMMISSIONING AND THE USE OF QOF DATA.

  The impact of practice-based commissioning on reducing health inequalities is currently unknown and needs proper evaluation. In terms of the current evidence it is likely that it is primary care commissioning that is likely to have the largest impact. Essential for this is a good understanding of the performance of all practices within a spearhead PCT. The Quality and Outcomes Framework (QOF) enables a start to be made, in areas of primary care where cost-effective interventions are important. The QOF system was not designed for monitoring population health—even at practice level—and needs to be interpreted with care. Eastern region PHO has provided helpful briefings on how to interpret QOF data. APHO has helped the process of interpreting the quality of patient care in areas where inequalities can be great by providing PCTs with estimates of the actual vs expected prevalence of diabetes—an important risk for CHD. The example below of practices within one London PCT shows which practices are failing to identify their expected diabetic patients and helps identify where support is needed. But it also shows that QOF data on its own is wide open to misinterpretation and does not record other key dimensions of inequality e.g. ethnicity, in any complete manner.

  The illustration above shows that in order for the whole PCT to level up and reduce its inequality gap, all poorly performing practices will need to do better. The National support team has identified this need for what it calls the "Industrialisation" of good practice in spearhead PCTs.

7.  WHAT IMPACT HAVE SPECIFIC INITIATIVES HAD AND IS THERE EVIDENCE OF INEQUALITIES WIDENING AS A RESULT OF NHS ACTION?

  Research evaluations of major initiatives such as Sure Start, regeneration programmes and the health action zones have been described by some as having a disappointing impact on health inequalities. But it is important to recognise that local initiatives form only one small part of an overall programme of national, local and individual action. There is evidence to show that tobacco control initiatives have only gained momentum over many years when government as well as the local NHS and partners have acted in concert. This is not yet the case for many other causes of inequality such as obesity and alcohol.

  Whilst the Acheson report on health inequalities cited strong evidence for both an inverse care and inverse prevention law operating in primary care, it is also clear that when inequalities are properly defined and resources properly re-directed to areas of greatest need, that parts of the inequalities pathway gap can be closed. This is true for the NHS smoking cessation service which has been shown by the Healthcare Commission and by independent research to be both clearly targeted to the most deprived areas, but also having its biggest impact in these areas.[297] The fact that the contribution of the NHS cessation service to overall tobacco reduction in a community is small compared perhaps with the potential impacts of the smoke free legislation reinforce the point that policies and practice need to be developed both by central government and by the NHS and its partners to be able to show a significant impact.

January 2008