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Holdroyd et al’s systematic review of the effectiveness of the English health inequalities strategy found that ambitious national targets set in 2001 for reducing inequalities in infant mortality and life expectation by 2010 were largely met. This is the only period in the last 50 years when inequalities in mortality between rich and poor have narrowed in England making this a considerable achievement and an historic result.
If policy makers are to maximise learning from this achievement, it’s important that they have a clear understanding of the interventions undertaken. The factors determining the distribution of health are complex and multifactorial. In any complex system, a strategy aimed at influencing outcomes needs to be as much about the approach to intervention as about the content of the policies (1). The papers Holdroyd et al cite are incomplete descriptions of the strategy as they omit the key elements that were central to the, resourcing, cross-sectoral incentivisation, metric generation and harnessing of power. Key elements of the intervention strategy included:
• The NHS Plan (2) that set out Government's commitment to the publication of national inequalities targets. The targets were published in February 2021. The detailed rational for the setting and construction of those targets was explained in a technical paper (3). Without knowing the exact impact of any one action the architects of the strategy believed that if inequalities...
• The NHS Plan (2) that set out Government's commitment to the publication of national inequalities targets. The targets were published in February 2021. The detailed rational for the setting and construction of those targets was explained in a technical paper (3). Without knowing the exact impact of any one action the architects of the strategy believed that if inequalities in mortality were to be reduced it was essential to address inequalities in the broad determinants of health . It was also believed that the cumulative impact on health and wellbeing of multiple cross sectional actions would be greater than the simple sum of the impact of individual actions.
• The inclusion of the national inequalities targets as central elements of the 2002 Spending Review. The Spending Review is the process by which multi-year budgets are set and targets agreed for all central Government departments. The government was explicit that their approach to tackling inequalities would be multi-sectoral: “ The Government is committed to narrowing the gap between the poorest neighbourhoods and the rest of the country…The 2002 Spending Review takes this strategy further ..... This puts in place deprivation related targets for education, employment, crime, health, housing, enterprise, road accidents and regional growth. " The consequence of putting inequalities at the heart of the spending review meant that spending departments didn’t get their money unless and until they agreed targets, developed plans and funded actions intended to address inequalities.
• The use of Public Service Agreements incorporating health and other inequalities targets for the performance management of all Whitehall spending departments with additional oversight from the Prime Minister's Delivery Unit. This created strong and aligned incentives across the public sector heavily focussed on reducing inequalities including health inequalities.
I believe the actions summarised above were at the core of funding, incentivising and securing long term coordinated multi-sectoral action across the public sector. Intractable problems can be tackled. But publishing strategies without considering the means for their delivery achieves very little. If we are to maximise our learning from the health inequalities strategy we need to pay attention to the ‘how’ as well the ‘what’.
1. Meadows D. Leverage points: places to intervene in a system.
2. NHS Plan. A plan for investment; a plan for reform. Department of Health (2000): 106-7 https://webarchive.nationalarchives.gov.uk/ukgwa/20050720205711/http://w...
3. Health inequalities – national targets on infant mortality and life expectancy – technical briefing . Department of Health March 2002 https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http://w...
4. Spending Reivew 2002: Public Service Agreements., HM Treasury 2002 para 1.12 https://webarchive.nationalarchives.gov.uk/ukgwa/20071204183446/http://w...