Critical policy issues when dealing with inequalities in health Sally Macintyre

Dealing with inequalities in health Lack of evidence about what works Some general policy principles

10 years ago (Acheson Report): conclusions from evaluation group lots of data documenting health inequalities lots of research attempting to explain health inequalities little information about effectiveness of interventions even less information about potential harms, costs or priorities evidence clearer for downstream than upstream interventions (Macintyre, Chalmers, Horton, Smith 1998)

Acheson enquiry evaluation group does not mean interventions aimed at whole communities are not effective, but rather reflects the paucity of good quality studies of these more upstream interventions many submissions to the enquiry (including one by me) consisted of wish lists of potentially useful interventions without evidence of their effectiveness in practice struck by the readiness of researchers to recommend policies the effectiveness of which they knew little about, in contrast to their caution in interpreting the results of epidemiological or clinical evidence (Macintyre et al, BMJ, 2001)

Public health intervention research HDA 2001 of published or funded public health research in UK, 4% deal with interventions rather than descriptions of the problem only 10% of those (0.4%) dealt with outcomes of interventions (Millward L, Kelly MP & Nutbeam D, 2001, Public Health Intervention Research: The Evidence, London, HDA )

(Wanless report: Securing good health for the whole population 2004) Although there is often evidence on the scientific justification for action and for some specific interventions, there is generally little evidence about the cost-effectiveness of public health and preventative policies or their practical implementation…

National Health Demonstration Projects, Scotland 2004 Poor evidence base in first place Evaluations set up too late Programmes non evaluable Decisions on phase 2 taken before evaluations complete (Evaluation Task Force Review, Scottish Executive, 2004)

House of Commons Health Committee 2009 Governments have spent large sums of money on social experiments to reduce health inequalities, but we do not know whether these experiments have worked or whether the money has been well spent. The latest initiative on Healthy Towns has all the failings of previous policies, indicating that the Government has learnt nothing from past mistakes.

House of Commons Health Committee 2009 There is an ethical imperative to develop and use evidence-based policy. All the reforms we have discussed are experiments on the public and can be as damaging (in terms of unintended effects and opportunity cost) as unevaluated new drugs or surgical procedures. Such wanton large-scale experimentation is unethical, and needs to be superseded by a more rigorous culture of piloting, evaluating and using the results to inform policy.

Why lack of evidence? Many evaluations focus on inputs, throughputs and customer or professional satisfaction rather than on outcomes. When evaluations do look at outcomes, health is often not studied. Few interventions are rolled out in ways which permit conclusive evaluation. Most evaluations focus on, and have sufficient sample size for, assessment of the overall effect but not on differential effects by SES. Policies may take some time to have the desired effects. Lack of UK studies.

Lack of robust evidence of effectiveness is not a justification for inaction. There are some general policy principles we could apply So what should we do?

What works? Does it work to improve health? Does it work to reduce health inequalities? It is important to note a distinction between two questions:

Because no effect on health inequalities if all SES groups benefit equally increase health inequalities if the rich benefit more reduce health inequalities if the poor benefit more An intervention which, in general, works (e.g. dental health education) might have:

Three levels of intervention: e.g. diet the structural or regulatory level (e.g. farming and trade policies, food labelling regulations, addition of vitamins to margarine and folate to flour) the local level (e.g. encouragement of food co-operatives, free fruit in schools, planning and rating policies to ensure the provision of affordable and healthy foods in deprived areas) individuals or families (e.g. nutrition education in schools or during pregnancy, mass media heath promotion advice, weight loss clinics in general practice).

Which are most effective? Interventions at the higher levels appear to do more to reduce health inequalities than information or individually based approaches.

More advantaged groups time finance coping skills literacy health More advantaged groups find it easier, because of better access to resources: to take up health promotion advice and preventive services, and to benefit from these.

Disadvantaged groups Tend: to be harder to reach find it harder to change behaviour to receive less benefit from lifestyle change or access to services

Disadvantaged groups Interventions with more disadvantaged groups may need to be much more intensive and targeted than might be appropriate for more advantaged groups:

More likely to reduce inequalities Structural changes in the environment Legislative and regulatory controls Fiscal policies Income support Reducing price barriers Improving accessibility of services Prioritising disadvantaged groups Offering intensive support Starting young

Less likely to reduce inequalities Information based campaigns Written materials Campaigns reliant on people taking the initiative to opt in Campaigns/messages designed for the whole population Whole school health education approaches Approaches which involve significant price or other barriers Housing or regeneration programmes that raise housing costs

Policy Issues 1 maintain and extend equity in health and welfare systems level up not down reduce inequalities in life circumstances, especially employment education income prioritise early years interventions, and families with children address upstream and downstream causes

Policy Issues 2 address both health care and non health care solutions target, and positively discriminate in favour of, both deprived places and deprived people remove barriers in access to health and non-health care goods and services prioritise structural and regulatory policies

Policy Issues 3 recognise need for more intensive support among more socially disadvantaged groups monitor the outcome of policies and interventions, both in terms of overall cost effectiveness and differential cost- effectiveness use robust principles of evaluation encourage partnership working across agencies, and involvement of local communities and target groups

Possibly competing goals Targeting the already advantaged may produce more aggregate health gain at relatively less cost. Targeting the disadvantaged may produce less aggregate health gain and at greater cost. Value judgments may have to be made about the relative priority to be given to aggregate health gain or reducing inequalities

Conclusions There is a lot of good evidence about the magnitude, direction and causes of, and trends in inequalities in health in different contexts Not matched by robust evidence about effectiveness or cost effectiveness of different strategies or interventions to reduce inequalities in health Some general principles and approaches that can be applied If evaluating the application of these principles into practice, need to use fit-for-purpose evaluation techniques

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