Equally Well: Report of the Ministerial Task Force on Health Inequalities

WHAT WILL SUCCESS LOOK LIKE?

Key points:

• It is important to measure progress in tackling health inequalities in the short, medium and long-term.
• The Task Force has recommended eight headline indicators around its priority areas for long-term change.
• Information and the evidence-base on what works need to be improved.

The Task Force wishes to set out what success in reducing health inequalities will look like in the short, medium and long-term and who is accountable for progress at these stages. The Task Force wishes to have a clear framework for this at both national and local levels, which is in keeping with the new relationship between the Scottish Government and local authorities.

Reporting progress in long-term trends in health inequalities

In the long term, success will be assessed in terms of a decline in inequalities in health outcomes which contributes to achieving the Government's overall purpose, strategic objectives and national outcomes. The Government will track and report progress at a national level.

The Task Force has had advice from a group of Government and external experts on appropriate high level population measures of health inequalities. This will form a new basis for measuring improvement over the longer term. The group has proposed a set of eight headline indicators of health outcomes and three inequalities measures of each. These are closely linked to the Task Force's priorities: early years, mental health and wellbeing, the big killer diseases and the cluster of problems related to drugs, alcohol and violence.

The expert group proposed the following headline indicators of inequalities in health outcomes:

• Healthy life expectancy (at age 25).
• Premature mortality (from all causes, aged under 75).
• Mental wellbeing (adults aged over 16).
• Low birth weight.

The group has also suggested measures of inequalities in morbidity and mortality from specific causes for specific age groups:

• Coronary heart disease ( CHD) (first ever emergency admission aged under 75; deaths aged 45-74)
• Cancer (incidence rate aged under 75; deaths aged 45-74)
• Alcohol (first ever hospital admission aged under 75, deaths aged 45-74)
• All-cause mortality (aged 15-44 years)

For each of these headline indicators, the expert group proposed the use of three measurement approaches in order to give a comprehensive picture of inequalities across the whole population. This addresses the problem with previous area-based health inequalities targets that only sought to improve the health of people living in the most deprived areas.

Relative Index of Inequality ( RII)	How steep is the inequalities gradient? This measure describes the gradient of health observed across the deprivation scale, relative to the mean health of the whole population
Absolute range	How big is the gap? This measure describes the absolute difference between the extremes of deprivation - the rate in the most deprived minus the rate in least deprived group
Scale	How big is the problem? This measure describes the underlying scale of the problem and past trends

These different measures give insight into different aspects of inequalities. The most fundamental of these differences is between absolute and relative measures of inequality. Where improvement has been seen across the population, the inequality gap might well have narrowed in absolute terms. However, improvements in the most deprived areas may not be as great as overall improvements observed in the population, meaning that the inequality gap has widened in relative terms. To be successful, both absolute and relative dimensions of inequalities should be reduced.

The new measures are illustrated at Annex 3 for premature mortality from CHD.

The Task Force considers that the expert group's proposals will give a much better basis for Government reporting on long-term success in reducing health inequalities and therefore recommends:

70. The Government should adopt the recommended new headline indicators and measures for reporting on long-term progress in reducing health inequalities in Scotland and driving action on the underlying causes of the most important inequalities.

71. The Government should publish in Summer 2008 detailed proposals for the new high level indicators and measures of health inequalities, along with current levels and trends for each measure.

Managing progress in the shorter term

As well as reporting on long-term, high-level trends in health inequalities, it is important to measure and manage progress in the short and medium-term. Local authorities, NHS Boards and other local partners should be looking at progress in the medium-term in addressing the underlying causes of health inequalities. In line with the Task Force's recommendation for action, agencies should be working separately and jointly to achieve outcomes which can be described as:

• Reduced inequalities in outcomes for children, eg literacy levels, school leaver destinations.
• Reduced inequalities in economic conditions and work environments, eg child poverty, low income, financial exclusion, unemployment.
• More equitable access to basic resources and services, eg adequate and affordable housing, neighbourhood satisfaction, reduced crime rates, opportunities for active travel.
• Reduced inequalities in individual health related behaviours, eg smoking, alcohol and drug misuse, domestic abuse.

Most of these outcomes are included in the National Performance Framework and the Single Outcome Agreement approach, which underpins the new relationship between the Scottish Government and local authorities. As well as contributing to reductions in health inequalities as above, they will also help to meet other Government objectives. These include economic, social and environmental goals.

These measures of underlying causes will therefore assist community planning partnerships and their member organisations to set priorities and plan actions to tackle health inequalities. They will allow agencies to assess the combined success of actions on the ground.

In the light of the Task Force's report, some further analysis is needed of whether the current set of national and local indicators provides enough coverage of the main factors causing health inequalities. We also need analysis of the causal links between these wider factors and influences and the priority health inequalities outcomes.

The Task Force therefore recommends that:

72. The Government should arrange for a clear analysis of the medium-term outcome indicators critical to achieving reductions in the key health inequalities outcomes. This analysis should reflect the National Performance Framework and the new relationship between the Scottish Government and local authorities as embodied in the Single Outcome Agreement process. It should be published by autumn 2008, in order to guide community planning partnerships and their constituent organisations in their own planning and performance reporting.

The Task Force expects this analysis to be tried out in local test sites and through the learning networks.

Within organisations, there are performance management systems, which monitor and manage progress towards longer term outcomes. For example, recent revisions to the NHS performance measures for health improvement in the HEAT targets reflect a re-focusing on the NHS contribution to delivering the relevant national outcomes and indicators. The HEAT targets relating to health inequalities are being further reviewed to ensure they focus on key areas where the NHS can make a critical contribution to long-term reductions in health inequalities.

Improving the evidence base

Throughout its work, the Task Force has found that there is not enough good evidence of what works in reducing health inequalities and influencing underlying causes.

The reasons for a lack of good effectiveness evidence to date were summarised for the Task Force by Professor Sally Macintyre. These include:

• Evaluations focusing on descriptions of the problem and on inputs, throughputs and customer or professional satisfaction, rather than on outcomes.
• When evaluations do look at outcomes, health outcomes are often not studied.
• Where health effects are assessed, the differential effects by socioeconomic status are rarely analysed.
• Interventions do not permit rigorous evaluation. Often they lack clear or measurable goals, baseline information, cost/benefit data and control or comparison groups or areas.
• Policies may take some time to have the desired effects.
• Lack of UK studies. It is not therefore clear whether policies that work within other geographical and cultural settings will also be effective in a UK or Scottish context.

In addition, most of the available evidence of what works comes from evaluating individual services, rather than looking at the results of joint efforts between organisations.

The Task Force therefore recommends that:

73. The Government should work with existing and new expert organisations in Scotland to develop a wider range of approaches to outcome and impact evaluation, appropriate for specific interventions and for complex and comprehensive packages of actions designed to reduce health inequalities.

The Government's support for learning networks and test sites should include approaches and resources for evaluation along these lines. In addition, the policies and actions that the Task Force recommends across the board should be implemented in ways that will allow for proper evaluations of their effectiveness. This should include looking at the differential impacts of policies and actions on different sub-groups in the population (socioeconomic, gender, ethnicity, etc.) and cost effectiveness.

Improving data on inequalities

The Task Force has heard that we do not yet have good enough information on inequalities in health outcomes across different groups in the population. Inequalities monitoring and indicators tend to focus on area deprivation. For example, over 90% of health care is provided through primary care services, yet almost no data are available to help assess whether these services are adequately meeting the specific needs of different groups within the population, which is a requirement of equalities legislation. This means it is not possible to use routine data to identify variations or trends in health and health care, nor to guide quality improvement initiatives. A major effort should be made to develop other appropriate indicators, starting with those areas where good data are available, such as gender and age.

The Task Force therefore recommends:

74. The Government should commission a review of health data needs which covers gender, ethnicity, age, disability, religion and belief, sexual orientation and transgender. The review should be published and include a plan of action with milestones to fill information gaps identified.

75. NHS targets should be set to support work on patient monitoring and collection of equalities data, led by the Equality and Diversity Information Project at NHS National Services for Scotland ( ISD).

76. The Government, with advice from relevant experts, should work towards better information to describe health inequalities based on socio-economic status, for example looking at low income of individuals, not just at average income of people living in a small area.

Assessing impact of policies and programmes

The Task Force has been concerned throughout its discussions to make sure that public sector organisations assess the impact which their policies and programmes have on health inequalities. The purpose of such assessment is to highlight potential health issues at an early stage in decision making. Better Health, Better Care has already recommended a systematic assessment of Government policies for their impact on health and potential contribution to reducing health inequalities. Better Health, Better Care also requires NHS Boards' decisions about service change and investment to be more routinely informed by health impact assessment and work is in hand to implement this.

The Task Force is aware of the multiplicity of impact assessments required of public sector organisations, either through legislation or policy. These include equalities, Strategic Environmental Assessment, carbon impact assessment and others. It acknowledges that an integrated impact assessment process is desirable, in which health issues are included alongside other types of impact. Information, evidence and development of staff skills and capacity are all critical in promoting impact assessment. The Task Force therefore recommends:

77. Integrated impact assessment processes for public policies and programmes should be developed and implemented at national and local levels, within constraints of the relevant formal systems. Impact on health inequalities should be a clear component. The Government should ensure that there is guidance and support to develop the knowledge and skills to enable impact assessment to be carried out, and health inequalities issues to be incorporated effectively.