Devolution and public health: the case of health inequalities

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Devolution and public health the case of health
inequalities

• Gareth Williams
• School of Social Sciences
• Cardiff University

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Key challenge

• We have no doubt that greater equality of
  health must remain one of our foremost national
  objectives and that in the last two decades of
  the twentieth century a new attack upon the
  forces of inequality has regrettably become
  necessary and now needs to be concerted
  Department of Health and Social Security, 1980
  (emphasis added)

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Policy Levels for Tackling Inequalities in Health
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Policy responses under New Labour

• Department of Health (1998a) Independent Inquiry
  into Inequalities in Health Report (Acheson
  Report), London HMSO
• Better Health, Better Wales (1998)
• Towards a Healthier Scotland (1998)
• Our Healthier Nation a Contract for Health
  (1998)
• Saving Lives Our Healthier Nation (1999)

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Key messages

• Commitment to tackling determinants of health and
  health inequalities
• Recognition that health services alone are not
  enough
• Growing emphasis on partnership and collaboration
  across policy sectors
• Support for public involvement
• Importance of evaluating what works

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Policy shifts in devolved territories, 1998-2005

• Wales, Scotland and England all show a move from
  structural perspectives on health inequalities to
  more individualistic ones
• Choosing Health (Secretary of State for Health,
  2004) In our survey, 88 of respondents agreed
  that individuals are responsible for their own
  health.
• Delivering for Health (Scottish Executive, 2005)
  We are working to encourage people to take
  greater control over their own health.
• Health Challenge Wales (Welsh Assembly
  Government, 2004) Health Challenge Wales asks
  every individual to consider what they are doing,
  and what more they could do, to improve their
  health and the health of their family.

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Priorities national and local

• Health inequalities may indeed be a national
  priority but it does not follow that this will
  necessarily precipitate local action. Issues may
  thus need to appear both on national and local
  agendas before implementation occurs
• Mark Exworthy et al, 2002

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Performance assessment and wicked issues the
case of health inequalities A 3 year study
comparing progress in England, Scotland and Wales

• Prof Tim Blackman
• Prof David Hunter
• Linda Marks
• Barbara Harrington

• Prof Lorna McKee
• Dr Alex Greene
• Prof Gareth Williams
• Dr Eva Elliott

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Implementing health inequalities policies

• England 2001 NHS commissioning organizations in
  most deprived areas required to demonstrate how
  they are narrowing life expectancy gaps with the
  national average against key targets
• Scotland 2004 adopted targets for improving
  health by measureable amounts amongst the most
  deprived, but not measured in relation to
  national average
• Wales 2004 adopted targets but not quantified,
  aiming for general reduction in mortality from
  CHD and cancer in deprived groups compared to
  national average
• Our study set out to understand what difference
  these devolved contexts had made to key actors
  talk about health inequalities

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What do health inequalities mean?

• In 2005 interviews
• Even in England the most target-driven
  territory there was no consensus amongst
  stakeholders about how to define health
  inequalities, let alone measure them
• Strong emphasis on an approach emphasising
  support for life-style change
• England and Scotland emphasis on how to narrow
  the gap Wales emphasis on how to improve poor
  health of the region in general

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Inequalities and priorities

• Its almost an ideological thing in the sense
  that it is a real drive from the Assembly to look
  at inequalities. But a lot of performance
  management is around hard stuff... the waiting
  times and chronic disease management (LHB CEO
  Wales)
• The Government is very much public opinion and
  target-driven and they want quick wins. You can
  get quick wins quicker by reducing waiting times
  than reducing health inequalities (Local
  Councillor, England)

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Devolutionary differences

• By second interviews (2007)
• England commitment to health inequalities
  influencing mainstream resource allocation
• Scotland strengthened resolve, but less evidence
  of effects on resource allocation
• Wales No strong national policy steer perceived
  locally and not addressed in local budgeting

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Divergence since 1998 but some evidence now of
convergence on fewer targets, more comparison and
performance management and contestability
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Examples of action at different policy levels

• Strengthening individuals
• Behavioural focus smoking cessation healthy
  eating
• Empowerment focus building self-esteem, coping
  skills
• Strengthening communities
• Community development SHARP Healthy Living
  Centres
• Community regeneration Communities First New
  Deal
• Access to facilities and services
• Safeguarding historical achievements health
  protection, education
• The new agenda Sure Start
• Structural and cultural change
• Call for more strategic approaches
• (Margaret Whitehead, 1995)

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Further reading

• Whitehead, M. (1995) Tackling inequalities a
  review of policy initiatives, in M. Benzeval et
  al (Eds.) Tackling Inequalities in Health and
  Agenda for Action, London Kings Fund
• Exworthy, M. et al (2002) How great expectations
  in Westminster may be dashed locally, Policy and
  Politics, 30, 79-96
• Blackman T, Elliott E, Greene A, Harrington B,
  Hunter D.J, Marks L, McKee L and Williams G.
  (2006) Performance assessment and wicked
  problems the case of health inequalities.
  Public Policy and Administration, 21, 2, 66-80.
• Harrington B.E, Smith K.E, Hunter D.J, Marks L,
  Blackman T.J, McKee L, Greene A, Elliott E and
  Williams G. (2009) Health inequalities in
  England, Scotland and Wales Stakeholders
  accounts and policy compared. Public Health, 123,
  24-28.
• Smith, K.E., Hunter, D.J., Blackman, T.,
  Williams, G., McKee, L., Harrington, B.E.,
  Elliott, E., Marks, L., Greene, A. (2009)
  Divergence or Convergence? The post-devolution
  health policies of England, Scotland and Wales,
  Critical Social Policy (in press)