The English strategy to reduce health inequalities : The Lancet

RSS Feeds

Welcome back, Dr. Pitarque Subscribe | My Lancet | Logout

Search for

in

All AllFields Fields Article Title, Abstract, Keywords

Submit

Advanced Search

Home | Journals | Specialties | Audio | Conferences | Education | The Lancet Series | Information for | Careers

The Lancet, Volume 377, Issue 9782, Pages 1986 - 1988, 11 June 2011

doi:10.1016/S0140-6736(10)62055-7

< Previous Article | Next Article >

Cite or Link Using DOI

Access this article on

SciVerse ScienceDirect

Published Online: 12 November 2010

The English strategy to reduce health inequalities Johan P Mackenbach a England is the first European country to pursue a systematic policy to reduce socioeconomic inequalities in health. When the Labour party came into power in 1997, it immediately commissioned an expert report 1 to develop a comprehensive programme to tackle health inequalities. 2, 3 The strategy has recently come to an end with the 2010 parliamentary elections, which brought a Conservative and Liberal Democrat coalition into government. So did this strategy reduce health inequalities? The strategy was structured around two overall targets: to narrow the gap in life expectancy between areas and the difference in infant mortality across social classes by 10% in 2010. The strategy was underpinned by 12 headline indicators (specific targets for intermediate outcomes) and 82 departmental commitments (specific actions by various governmental departments), which together should ensure timely delivery of targets. The departmental commitments included reduction in child poverty, Sure Start, smoking cessation services, primary care in inner cities, and better access to treatment for cancer and cardiovascular disease. The total budget exceeded £20 billion. 3 Official reviews give a clear picture of the results. 4—8 While the departmental commitments were mostly met, only about half of the headline indicators were achieved and the outcome targets were completely missed. Some of the headline indicators show reduced inequalities, but others, including those that matter for inequalities in life expectancy or infant mortality, suggest stable or even increased inequalities between socioeconomic groups (table). The gap in life expectancy grew, because the national average has improved at a much higher speed than life expectancy in deprived areas. The same applies to the gap in infant mortality.4

Article Options Full Text PDF (49 KB) Printer Friendly Version Request permission Export Citation Create Citation Alert

Linked Articles Editorial “Claptrap” from the UK's Department of Health Other Articles of Interest Public Health Tackling socioeconomic inequalities in health: analysis of European experiences Articles Socioeconomic

inequalities in morbidity and mortality in western Europe

Perspectives The challenge of health inequalities

Public Health Ethics of the social determinants of health

Table Table image Achievement of the headline indicators in the 2003 Programme for Action 3 Why was the strategy not more successful? In hindsight, at least three causes can be identified. First, it did not always address the correct entry points. It spent huge resources on entry points which were not relevant for life expectancy or infant mortality within the timeframe of the strategy (eg, Sure Start, neighbourhood renewal, fuel poverty), and it almost completely ignored other relevant entry points (eg, income inequality, working conditions, excessive alcohol consumption). Second, the strategy was unable to use effective policies. At the start, there was almost no evidence on effectiveness of policies to reduce health inequalities, 9 and to the extent that policies were evaluated during implementation most proved to be largely ineffective in reducing inequalities in health outcomes. 10—12 Third, the strategy was not delivered on a large enough scale. Unfortunately, the scale required for achieving population-wide impacts was not determined in advance, and later analyses showed many examples of misalignment between departmental commitments, headline indicators, and overall targets.8 Where reach was part of the evaluation, as in the case of smoking cessation, it proved to be insufficient to have an impact on inequalities at the population level.12 Were these failures caused by a lack of determination on the part of government? For those who are familiar with the situation in other western European countries, it is clear that despite all its weaknesses 13 , 14 the Labour government was probably the most determined ever to tackle health inequalities. The explanation should therefore be sought elsewhere. First, the

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62055-7/fulltext?_eventId=login[10/06/2011 8:36:58]

Series Health care and equity in India Bookmark Delicious Digg reddit Facebook StumbleUpon

The English strategy to reduce health inequalities : The Lancet

suboptimum choice of entry points reflects the necessity for this (or any) government to match scientific evidence with political opportunity, and the lack of a democratic mandate to take more radical action. Labour had been elected on the basis of a party programme that simply did not include a radical redistribution of income or wealth. Second, the choice of inadequate policies reflects the lack of scientific evidence on effectiveness of policies to reduce inequalities. This in turn was due to the relatively short time which had elapsed between the identification of the determinants of health inequalities (mostly in the 1980s and 1990s) and the urgent need of a newly elected and eager government to be advised on what it could do to tackle health inequalities. Third, the insufficient scale of implementation reflects a fundamental discrepancy between the necessary scale of change to tackle health inequalities and the ability of state bureaucracies to change in response to new priorities.6 If my analysis is correct, the way forward includes the following ingredients. First, more advocacy is needed to make sure that elected governments have a democratic mandate to make the necessary policy changes. Reducing health inequalities requires large-scale policy change in many fields, and this change will not come about without articulation in political parties' programmes. Second, more research is needed into the effectiveness of policies targeting the drivers of health inequalities. This research can only be done appropriately if policies are systematically tested before they are widely implemented, and if resources are made available to do these expensive evaluations. International collaboration will be needed to increase learning speed. Third, the necessary scale of implementation can only be achieved by more focused policy efforts, based on careful alignment of targets, commitments, and delivery. Strategies need to focus exclusively on drivers of health inequalities, and make sure that the scale of implementation of policies matches the numbers of people needing to be reached and the degree of environmental or behavioural change to be induced. For the foreseeable future, we need less ambitious aims combined with more focused approaches and more rigorous evaluation.

For the Lancet UK Policy Matters website see http://UKpolicymatters.thelancet.com/

I declare that I have no conflicts of interest.

References 1 Acheson D. Independent inquiry into inequalities in health. http://www.archive.officialdocuments.co.uk/document/doh/ih/ih.htm. (accessed Sept 18, 2010). 2 Department of Health. Reducing health inequalities: an action report. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006054. (accessed Sept 18, 2010). 3 Department of Health. Tackling health inequalities: a programme for action. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008268. (accessed Sept 18, 2010). 4 Department of Health. Tackling health inequalities: 2007 status report of the programme for action. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083471. (accessed Sept 18, 2010). 5 Department of Health. Tackling health inequalities: 10 years on. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098936. (accessed Sept 18, 2010). 6 House of Commons Health Committee. Health Committee third report: health inequalities. http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/28602.htm. (accessed Sept 18, 2010). 7 Global Health Equity Group. Fair society, healthy lives (the Marmot review): a strategic review of health inequalities in England post-2010. http://www.marmotreview.org. (accessed Sept 18, 2010). 8 Comptroller and Auditor General, National Audit Office. Tackling inequalities in life expectancy in areas with the worst health and deprivation. http://www.nao.org.uk/publications/1011/health_inequalities.aspx. (accessed Sept 18, 2010). 9 MacIntyre S, Chalmers I, Horton R, Smith R. Using evidence to inform health policy: case study. BMJ 2001; 322: 222-225. CrossRef | PubMed 10 Judge K, Bauld L. Learning from policy failure? Health action zones in England. Eur J Public Health 2006; 16: 341-344. CrossRef | PubMed 11 Melhuish E, Belsky J, Leyland AH, Barnes Jthe National Evaluation of Sure Start Research Team. Effects of fully-established Sure Start Local Programmes on 3-year-old children and their families living in England: a quasi-experimental observational study. Lancet 2008; 372: 1641-1647. Summary | Full Text | PDF(97KB) | CrossRef | PubMed 12 Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tob Control 2007; 16: 400-404. CrossRef | PubMed

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62055-7/fulltext?_eventId=login[10/06/2011 8:36:58]

The English strategy to reduce health inequalities : The Lancet

13 Shaw M, Smith G Davey, Dorling D. Health Inequalities and New Labour: how the promises compare with real progress. BMJ 2005; 330: 1016-1021. CrossRef | PubMed 14 McKee M, Raine R. Choosing health? First choose your philosophy. Lancet 2005; 365: 369-371. Full Text | PDF(129KB) | CrossRef | PubMed a Department of Public Health, Erasmus MC, 3000 CA Rotterdam, Netherlands Privacy Policy | Terms & Conditions | Contact Us | About Us Copyright © 2011 Elsevier Limited. All rights reserved. The Lancet ® is a registered trademark of Elsevier Properties S.A. used under licence. The content on this site is intended for health professionals.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62055-7/fulltext?_eventId=login[10/06/2011 8:36:58]