Feature

Inequalities in health: whose baby?

The government wants the fledgling primary care trusts to take responsibility for meeting targets to reduce health inequalities. But it makes more sense for local authorities to take the lead, argues Fiona Campbell

Last year, for the first time, the government set national targets for reducing health inequalities. Everyone – even the sceptics – welcomed this as an indication of commitment. But recent research suggests that health inequalities in the UK are increasing rather than decreasing,^{1 2 3} so drastic measures will need to be taken to reverse that trend and meet the not-very-ambitious national targets.

The lead for local action on health inequalities rests with primary care trusts, partly because of their public health role, partly because of their role as local leader of the HIMP (Health Improvement and Modernisation Programme) process.

This indicates a failure of imagination or nerve on the part of the government. Just because measuring health outcomes goes on in the NHS, it does not mean that what is measured is necessarily wholly or even mainly under the control of health service providers, as the government has explicitly acknowledged.

Public health and other NHS workers are well aware of this, as some of the imaginative work in Health Action Zone areas attests (go to www.haznet.org.uk for examples).

Should PCTs have responsibility for tackling health inequalities? The Democratic Health Network believes not. We have proposed to the Commission on Local Governance (set up by the Local Government Information Unit in 2001 and reporting in June 2002) that local authorities should take the lead on health inequalities. Here are some of our reasons.

Capacity problems and PCTs

The abolition of health authorities (and the transfer of some of their powers upwards to strategic health authorities and downwards to primary care trusts) has led to confusion about where strategic planning on health inequalities should be taking place.

There has been much debate about whether PCTs are even geared up to undertake their ‘core business’ – commissioning and delivering effective ‘sickness services’ – let alone the more long-term action necessary to make a real difference to the health gap.

Added to this there are serious capacity problems. Many PCTs have inherited budget deficits and have few resources to devote to long-term strategic measures, or to brokering the kind of imaginative joint planning that will be required to make real inroads into inequalities.

This is not to say that there is a lot of spare capacity in local government, but much of the core business of local government has a health impact so, in one sense, work on health inequalities is already going on within local authorities.

However, this work needs to be made much more explicit, so that the health component of ideas of ‘good housing’, ‘appropriate public transport’ and ‘regeneration’ are understood. No PCT is going to be in a position to get to the heart of local government business in a way that local authorities themselves can do.

The power of plans

The Local Government Act 2000 confers on local authorities the power to take action to improve the social, economic and environmental well-being of the communities they serve. It is difficult to imagine that community well-being can co-exist with health inequalities. And yet almost every local authority area, even the most affluent, has areas and groups of people whose health and life expectancy differ significantly.

The only local authorities with little variation in health among different groups in their populations are the very poorest areas, where mortality rates throughout are worse than the average. But these areas can hardly be described as in a state of ‘well-being’.

If local authorities are to take this power seriously – and its associated duty to produce a community plan – they will need to ensure that their plans contain strategies to tackle health inequalities.

Some local authorities have done this by including the section of their local HIMP that refers to health inequalities in their plans. But, so far, many local HIMPs have included very little reference to health inequalities or to ways in which local authorities can work to address this.⁴

Even where a HIMP has a substantial section on health inequalities, it does not seem a feasible way for local authorities to incorporate action directed at reducing health inequalities into their planning, service and policy areas.

Much of the work of local authorities, including regeneration, housing, education, leisure, transport and the environment, has an impact on health inequalities, in some cases a greater impact than health services. But unless local authorities see themselves as the leaders in this field, we are unlikely to see them developing strategies for prioritising action on health inequalities.

The ‘community leader’ role

The Local Government Act 2000 also underlines the ‘community leadership’ role of local authorities. This is partly a sop to local government, many of whose direct service delivery functions have been taken away by successive governments in the past 25 years.

Nonetheless, it is not an empty concept and includes within it government recognition of local authorities as co-ordinators and facilitators of partnership working. Real cross-cutting action is essential if the complex socio-economic causes of health inequalities are to be addressed.

The community leadership role of local government appears to provide an ideal opportunity to seize the initiative in this area. The kind of co-ordination needed includes collaboration across the different public sector services, as well as working with the voluntary and private sectors.

We believe that a strong community lead is necessary if targets to reduce health inequalities are to be met, and that this will not come from new organisations under pressure to deliver mainstream health services.

Health inequalities and scrutiny

Taking the lead on health inequalities could complement local authorities’ new health scrutiny role, due to come into force in January 2003 under the Health and Social Care Act 2001.

The consultation document, issued in January, says the aim of health scrutiny is ‘to act as a lever to improve the health of local people – by addressing... health inequalities between different groups – to secure the continuous improvement of health services and services that impact upon health’.

This provides enormous scope for local authorities to look not only at NHS services, but also at other parts of the public sector, the private sector, and at what they themselves are doing that affects health inequalities.

Ideally, the scrutiny role is about assisting everyone in the health locality – including the local authority itself – to develop policy based on evidence that comes directly from patients and service users and, crucially, from those who are currently excluded from using services or for whom there are no appropriate services.

The first health scrutiny exercises are showing that local authorities take their own health role seriously. For example, one local authority has conducted a review of how it and local health bodies are working together to make the best use of ‘winter pressures’ funding for older people’s services. Another is contemplating looking at local employment (including its own) of people with mental health problems.

If councils and their executives had overall responsibility for leading on health inequalities issues, we believe that the policy development side of health scrutiny would become a higher priority within local government, as well as within the local NHS.

Addressing local issues

The government wants to ensure equality of access and treatment across the country, but the panoply of central government measures may lead to lower NHS morale, a ‘checklist’ mentality and a failure to take account of local variation in population and healthcare needs.

There are inequalities within communities, as well as between them, and there are local economies as well as a national one – facts that the regeneration, anti-poverty and equalities strategies of local authorities are designed to address.

‘Postcode prescribing’ is iniquitous when it means that two people in similar circumstances in different parts of the country have different entitlements to treatment. But postcode prescribing is necessary to enable a response to the different socio-economic circumstances experienced by different groups. In fact, a benign version of postcode prescribing is precisely what local authorities administer when they address inequalities of gender, race and class within their electorates.

PCTs are still young organisations, taking on enormous responsibilities and, in many cases, large budget deficits. By handing them the lead on health inequalities, the government could be adding one burden too many. For local authorities, this responsibility might require some reconsideration and reshaping of their core duties to ensure there is an explicit consideration of health gaps, but initiatives such as Health for All demonstrate that a strong lead on health inequalities is well within the capabilities of many local authorities.