1. Wicked issues and performance assessment: The case of health inequalities A comparative study of England, Scotland and Wales 2007-09 Prof Tim Blackman Prof David Hunter Linda Marks Barbara Harrington Prof Lorna McKee Dr Alex Greene Prof Gareth Williams Dr Eva Elliott

5. Do targets matter? ‘The targets have driven change. Would this have happened without them? The answer is perhaps … but not as quickly or effectively’ (PCT performance manager, England) ‘You’re not going to see any savings for maybe twenty years … So it’s not about we’ll stop treating people for heart attacks and instead we’ll stop them smoking’ (Health Board performance manager, Scotland) ‘League tables are a bit unhealthy … every area has particular issues and problems’ (Health Board Director, Wales).

6. Joint outcome agreements Scotland –(New) Single Outcome Agreements –Community Planning Partnerships –A development of partnership working England –Local Area Agreements –Local Strategic Partnerships –A development of performance assessment Wales –(New) Local Delivery Agreements, linked to Health, Social Care and Well-being Strategies –Local Service Boards –Ministerial oversight –Sharper focus in second round HSCWB strategies on ‘baselines and objectives’

7. Reorganisation Wales –Planned and ongoing reorganisations to health boards and public health services England –Larger PCTs or joint management arrangements –Some local government reorganisation into larger councils

8. Partnerships ‘Working well’ in Scottish localities –Some long-standing relationships –‘Working together’ a value, different to England Mixed views in the English localities –A forum –Variable real engagement –Health inequality targets mainstreamed in PCTs but not in local councils Mixed views in the Welsh localities (mostly negative) –More about collaboration between health and social care services than health improvement –Building trust still an issue –Funding regarded as an impediment

9. Success? ‘We know we have vastly improved our performance. We know we’ve increased life expectancy for men and women. We know we’ve got smoking rates down. We still have massive problems but we feel we have made a significant improvement especially when compared against our neighbouring authorities who have similar issues. It’s a combination of the right evidence base and the right indicators in place to measure it, but obviously we’ve had extremely good partnership working and strong leadership to drive things forward’.

10. Challenges Being methodical: –‘It’s much more amenable to something like sickness absence or waiting times, where it’s very good. Where it’s much more difficult, but I think still applicable, and the discipline or it is very good, it’s much more difficult when you’re starting to look at behaviour change and health improvement, which is long term, it’s multifactorial’ (Scotland) Making the case –‘We keep reminding people that health inequalities are widening but it’s not helpful in that it hasn’t actually made a difference to the outcomes for the individuals that we need to be concerned about’ (Scotland)

11. In Wales performance management was skewing attention away from health improvement and health inequalities –‘I’m not saying that we’re told not to deliver on health inequalities but you’ve got to achieve the service targets … the number one priorities such as waiting times for accident and emergency, cancer and cardiac‘.

12. Constructing ‘health inequalities’ Health inequalities were widely seen in all countries as caused by deprivation –but to manifest as ‘cultural’ issues about deep-seated unhealthy behaviours and low aspiration Commissioning in the English localities was said to be resourcing large-scale screening and awareness-raising programmes –said to be evidence-based but driven by performance assessment and availability of models for secondary prevention. Commissioning in Wales –No driver from Health, Social Care and Well-being Strategies

13. Local councils regarded their mainstream services as intrinsically likely to reduce health inequalities –Specific exceptions were mainly measures to reduce smoking, alcohol consumption and fuel poverty, and generally targeting deprived areas. –No modelling ‘The local authority has levers, relevant to lots of little determinants … some of these are not priorities for the local authority so although they’re in their gift the local authority tends to see itself as a series of delivery empires’ (Wales)

14. Intervention – at what level? Life expectancy targets not something than can be performance managed More talk about performance managing interventions in the key causes of life expectancy gaps –‘We realised a couple of years ago that actually we were potentially increasing health inequality’ (DPH, England)

15. More causal chain thinking starting to develop –‘So we need to be clear about assumptions and we are going to judge whether that in fact has been a factor or whether it’s other factors …’ (Scotland) –Now we’re focusing on our harder to reach groups … the whole task of behaviour change is harder because they’ve got more baggage and problems. It’s OK but it’s hard.’ (England) Wales tended to be an exception –More of a view that health inequalities could only really be addressed with long-term economic and fiscal measures, with the NHS meanwhile managing the post-industrial legacy of chronic ill-health.

16. Break-out groups Health inequality targets –Driving change? –Too short-term? –Invite unhelpful comparisons? Joint outcome agreements and strategies –Just different targets? –Joining up actions effectively? Partnerships –Working well? –Delivering? Reorganisations –Helpful or damaging? For all questions: What can be learned from national comparisons? Has our research missed any key issues?