1. Devolution and public health: the case of health inequalities Gareth Williams School of Social Sciences Cardiff University

2. Key challenge We have no doubt that greater equality of health must remain one of our foremost national objectives and that in the last two decades of the twentieth century a new attack upon the forces of inequality has regrettably become necessary and now needs to be concerted – Department of Health and Social Security, 1980 (emphasis added)

3. Policy Levels for Tackling Inequalities in Health

4. Policy responses under New Labour Department of Health (1998a) Independent Inquiry into Inequalities in Health – Report (Acheson Report), London: HMSO Better Health, Better Wales (1998) Towards a Healthier Scotland (1998) Our Healthier Nation: a Contract for Health (1998) Saving Lives: Our Healthier Nation (1999)

5. Key messages Commitment to tackling determinants of health and health inequalities Recognition that health services alone are not enough Growing emphasis on partnership and collaboration across policy sectors Support for public involvement Importance of evaluating what works

6. Policy shifts in devolved territories, 1998-2005 Wales, Scotland and England all show a move from structural perspectives on health inequalities to more individualistic ones: Choosing Health (Secretary of State for Health, 2004): In our survey, 88% of respondents agreed that individuals are responsible for their own health. Delivering for Health (Scottish Executive, 2005): We are working to encourage people to take greater control over their own health. Health Challenge Wales (Welsh Assembly Government, 2004): Health Challenge Wales asks every individual to consider what they are doing, and what more they could do, to improve their health and the health of their family.

7. Priorities: national and local Health inequalities may indeed be a national priority but it does not follow that this will necessarily precipitate local action. Issues may thus need to appear both on national and local agendas before implementation occurs Mark Exworthy et al, 2002

8. Performance assessment and wicked issues: the case of health inequalities A 3 year study comparing progress in England, Scotland and Wales Prof Tim Blackman Prof David Hunter Linda Marks Barbara Harrington Prof Lorna McKee Dr Alex Greene Prof Gareth Williams Dr Eva Elliott

9. Implementing health inequalities policies England 2001: NHS commissioning organizations in most deprived areas required to demonstrate how they are narrowing life expectancy gaps with the national average against key targets Scotland 2004: adopted targets for improving health by measureable amounts amongst the most deprived, but not measured in relation to national average Wales 2004: adopted targets but not quantified, aiming for general reduction in mortality from CHD and cancer in deprived groups compared to national average Our study set out to understand what difference these devolved contexts had made to key actors talk about health inequalities

10. What do health inequalities mean? In 2005 interviews: Even in England – the most target-driven territory – there was no consensus amongst stakeholders about how to define health inequalities, let alone measure them Strong emphasis on an approach emphasising support for life-style change England and Scotland – emphasis on how to narrow the gap; Wales – emphasis on how to improve poor health of the region in general

11. Inequalities and priorities Its almost an ideological thing in the sense that it is a real drive from the Assembly to look at inequalities. But a lot of performance management is around hard stuff... the waiting times and chronic disease management (LHB CEO Wales) The Government is very much public opinion and target-driven and they want quick wins. You can get quick wins quicker by reducing waiting times than reducing health inequalities (Local Councillor, England)

12. Devolutionary differences By second interviews (2007): England: commitment to health inequalities influencing mainstream resource allocation Scotland: strengthened resolve, but less evidence of effects on resource allocation Wales: No strong national policy steer perceived locally and not addressed in local budgeting

13. Divergence since 1998 but some evidence now of convergence on fewer targets, more comparison and performance management and contestability EnglandWalesScotland Markets and management. Distrust of professionals. New Labour choice agenda and creative discomfort. Localism and collaboration. Strong role for local councils in health Professionally-led networks and hierarchies; consultation and planning Competition and naming & shaming in the NHS – extended to health inequalities amid service redesign Integrated NHS still with purchaser-provider but strongly localist. Wider determinants model eclipsed by waiting times and NHS redesign Integrated NHS, professionally driven with partnership ethos. Focus on health improvement and service redesign. Targets and naming & shaming in local government, now with health as a shared priority Performance management in local government but with fewer targets and few comparisons

14. Examples of action at different policy levels Strengthening individuals Behavioural focus – smoking cessation; healthy eating Empowerment focus – building self-esteem, coping skills Strengthening communities Community development – SHARP; Healthy Living Centres Community regeneration – Communities First; New Deal Access to facilities and services Safeguarding historical achievements – health protection, education The new agenda – Sure Start Structural and cultural change Call for more strategic approaches ( Margaret Whitehead, 1995)

15. Further reading Whitehead, M. (1995) Tackling inequalities: a review of policy initiatives, in: M. Benzeval et al (Eds.) Tackling Inequalities in Health: and Agenda for Action, London: Kings Fund Exworthy, M. et al (2002) How great expectations in Westminster may be dashed locally, Policy and Politics, 30, 79-96 Blackman T, Elliott E, Greene A, Harrington B, Hunter D.J, Marks L, McKee L and Williams G. (2006) Performance assessment and wicked problems: the case of health inequalities. Public Policy and Administration, 21, 2, 66- 80. Harrington B.E, Smith K.E, Hunter D.J, Marks L, Blackman T.J, McKee L, Greene A, Elliott E and Williams G. (2009) Health inequalities in England, Scotland and Wales: Stakeholders accounts and policy compared. Public Health, 123, 24-28. Smith, K.E., Hunter, D.J., Blackman, T., Williams, G., McKee, L., Harrington, B.E., Elliott, E., Marks, L., Greene, A. (2009) Divergence or Convergence? The post-devolution health policies of England, Scotland and Wales, Critical Social Policy (in press)