Aches on Report

8/8/2019 Aches on Report

1/43

ACHESON REPORT

THE INQUIRY INTO INEQUALITIES IN HEALTH

IMPLICATIONS FOR LONDON

A DISCUSSION PAPER

April 1999

Prepared by

Caroline LowdellMartin BardsleyDavid Morgan

Health of Londoners Project

Directorate of Public HealthEast London & The City Health Authority

Aneurin Bevan House81-91 Commercial Road

London, E1 1RDTel: 0171 655 6778Fax: 0171 655 6770

Email: [email protected]


2/43i

ACHESON REPORT- THE INQUIRY INTO INEQUALITIES IN HEALTH:IMPLICATIONS FOR LONDON

EXECUTIVE SUMMARY

This paper is for information and discussion. It responds to the publication in

November 1998 of the report of the Independent Inquiry into Inequalities in Health,chaired by Sir Donald Acheson. This paper is aimed at health authorities and otherswithin the health service, and with an interest in health, in London: it1. provides a summary of Acheson Reports main findings and recommendations;2. considers key aspects of inequality in London and examines some issues in the

measurement of inequality in health across London;3. relates Achesons recommendations to the London context.

1. CONTEXT AND SUMMARY OF ACHESON REPORT.

This Inquiry into Inequalities in Health, reporting almost 20 years after the Black Report, has been welcomed in general terms by the Department of Health whichestablished it, without as yet receiving a formal response. Acheson explored a widerange of determinants of health, and the recommendations are addressed toGovernment as a whole, not simply DoH or the NHS. Policy emerging over thecoming months - including fiscal and economic measures as well as the White Paperto progress Our Healthier Nation will show the extent of its acceptance.

The Inquirys Terms of Reference comprised information review; identification of evidence-based priorities for action; reporting for publication and as a contribution tothe development of a new strategy for health. Costing was explicitly excluded from

its remit.

Its findings on inequalities in health and its determinants, while showing someimproving trends, also demonstrate persistent differentials, and that some, includingthose in income and in mortality rates per social class, have increased. (The findingsfor England, and the London position where known, are summarised at Appendix A.)

Of 39 main recommendations, many of them with sub-recommendations, the threewith the highest priority are:1. That as part of health impact assessment, all policies likely to have an impact on

health should be evaluated in terms of their impact on health inequalities, and

formulated in such a way that by favouring the less well off they will, whereverpossible, reduce such inequalities.2. That a high priority is given to policies aimed at improving health and reducing

health inequalities in women of childbearing age, expectant mothers and youngchildren.

3. Policies which will further reduce income inequalities, and improve the livingstandards of households in receipt of social security benefits.

There is no other prioritisation between the remaining recommendations (given insummary form at Appendix B) of which some are broad-based, some very specific.


3/43ii

Findings and recommendations relate to: five further policy areas: education; employment; housing and environment;

mobility, transport and pollution; nutrition and the Common Agricultural Policy; five population groupings or dimensions: mothers, children and families; young

people and adults of working age; older people; ethnicity; and gender; principles and practice in the National Health Service: equity of access; more

equity in resource allocation; equity profiles and progress audits.

2. OVERVIEW OF HEALTH INEQUALITIES IN LONDON

To relate inequalities to the London context, a brief review of health inequalities inLondon is given, and some initial analyses of available data are used to explore boththe levels of inequality within London, and some methodological issues.

General health indicators such as premature mortality rates suggest that London is,overall, not the most unhealthy place. However within London there are some

inner city areas where indicators point to poor levels of health. Moreover thetrends in mortality in London are not improving as fast as national averages.London also shows some specific health problems including high levels of HIV/AIDS, mental health problems, drug abuse and infectious disease.

London fares poorly on a number of social and economic indicators includingeducational attainment, unemployment, homelessness and poor housing, andcrime rates. London also shows an extreme distribution of income includingproportionately more of the most wealthy and the poorest.

The population of London is relatively young, mobile and the most ethnicallydiverse of all UK cities.

Access to secondary and tertiary health services in London is generally good, butaccess to primary health care, relatively poor, especially in the inner city.

Many of the data sources used to illustrate inequality in the Acheson report are notavailable at a local level. The most abundant data relate to geographic areas such aswards or boroughs. The advantages and disadvantages of a geographic approach arediscussed using premature mortality rates (below age 75) as an example. It isimportant to note that this analysis is based on relative rates (against the nationalaverage) and that absolute mortality rates are falling. Some of the conclusions fromthe analysis are:

The range in premature mortality rates at borough level within London extendsfrom 20% below national average to 35% above.

Within each borough, and even in the most affluent parts of the city, there aresignificant differences in mortality between wards.

There are many different ways to quantify the extent of inequality, and noaccepted standard. The extent of health inequality between wards (as measuredon SMR


4/43iii

The data suggest that the increasing gap in relative mortality rates is due mainly toa worsening in the least healthy wards.

These are preliminary analyses: some alternative indicators and methods aresuggested.

3. IMPLICATIONS OF THE REPORT AND ITS RECOMMENDATIONS FORHEALTH AUTHORITIES IN LONDON

The changes associated with The New NHS are accompanied in London by theestablishment of the London Regional Office of the NHS, and the development of aGreater London Authority with a directly elected mayor. The GLAs proposedresponsibilities, all with some indirect health impact though they exclude healthservices, are summarised at Appendix C.

Achesons recommendations are addressed at reducing inequalities in thedeterminants of health, or at making better provision for those disadvantaged bydifference. Levelling-up for the worst off, rather than any levelling down, isproposed. While some of his recommendations are targetted at relatively small

groups, the recommendation on reducing income inequalities while improving livingstandards for those on social security benefits, has a very broad application, and alsocost implications.

If inequalities reduction is pursued as a priority, the level of application whetherwithin or between NHS Regions, Londons five sectors, or Health Authorities andboroughs, will be critical in determining the initiatives required to meet it. At aLondon-wide level, the requirement to assess the impact of all its policies on healthinequalities may, depending partly on legislation and partly on political preference,become a responsibility of the future GLA. Resources and mechanisms in London forthis special case of health impact assessment, need further consideration.

The Inquirys recommendations require a response by a number of sectors farbeyond the NHS and its usual partners and at a number of levels:

National government policy change, or action by government departments oragencies at a national level, for example environmental or employment measures.

At a regional level, some recommendations would require GLA support, or actionby GLA - linked statutory bodies - for example transport and environmentpolicy: again the GLAs role in terms of partnership with the NHS, and whetherthis can be with the Regional Office or with Health Authorities collectively, needsclarification.

Health Authorities and increasingly Primary Care Groups or Trusts would need towork with Local Authorities, other NHS providers and a wide range of otherbodies, for example in developing pre-school education, the care of looked-afterchildren, the role of health visitors in family support, and suicide prevention.

More locally still, employers, individual schools in public as well as voluntaryand private sectors, community groups, families and individuals must becommitted to ensure these recommendations are met.


5/43iv

The roles of Health Authorities include: some specific responsibilities for work as local health and health service policy

leaders for example through Health Improvement Programmes; tackling inequalities as local NHS employers, through healthy employment and

transport policies; working through local partnership; influencing policy at national and regional levels; accommodating the resource implications of suggested resource shifts and reviews

such as deprivation payments and the private healthcare sector; promoting equity of access to health care; production of equity profiles and the development and monitoring of joint

programmes through health inequalities impact assessment.


6/43v

CONTENTS

EXECUTIVE SUMMARY i

CONTENTS v

SECTION A: INTRODUCTION AND SUMMARY OF FINDINGS ANDRECOMMENDATIONSIntroduction 1Context of the report 1Evidence of inequalities in health and its determinants 2

Findings and Recommendations 2

SECTION B: UPDATE ON HEALTH INEQUALITIES IN LONDONOverview of health inequalities in London 4Measuring inequality in London 5

Differences between districts/boroughs within London 6Differences within districts/boroughs 7Comparing the distribution of health status across wards 7

Trends at ward level within boroughs 13Trends in health and deprivation by ward across London 15Conclusions 17

SECTION C: IMPLICATIONS OF THE REPORT AND ITS RECOMMENDATIONS FORHEALTH AUTHORITIES AND OTHERS IN LONDONLondon context 19Achesons overall approach to inequalities, and the key priorities 19Recommendations, and who might implement them 21Conclusions and key roles for health authorities in London 23

REFERENCES 25

APPENDIX A: Inequalities in Health: Findings for England, Position in London where known 27

APPENDIX B: Summary of Recommendations: who might implement them in London 31

APPENDIX C: Greater London Authority Functions 37


7/431

ACHESON REPORT- INQUIRY INTO INEQUALITIES IN HEALTH:IMPLICATIONS FOR LONDON

SECTION A: INTRODUCTION TO ACHESON REPORT, SUMMARY OFFINDINGS AND RECOMMENDATIONS

INTRODUCTION

The report of the Independent Inquiry into Inequalities in Health, led by Sir DonaldAcheson, was published at the end of November 1998 (Dept of Health 1998 (a)).This paper is for information and discussion. It is aimed at health authorities andothers within the health service, and with an interest in health, in London. Section Asummarises the reports main findings and recommendations. Section B relatesinequalities in London to the findings for England, and sets out some findings andissues from new analyses of inequalities in health across London. Section C relatesAchesons recommendations to the London context.

1. CONTEXT OF THE REPORT

The Inquiry has reviewed evidence on inequalities in health in England, and identifiedareas for policy development likely to reduce them. It has related these to the socio-economic determinants of health as well as to environment and lifestyle, and also tostages of the life course, ethnic and gender inequalities. This means that some of therecommendations for action are addressed to Government as a whole, while others areaddressed to specific departments, of which D o H is only one, or to the NHS. Unlikeits predecessor produced almost 20 years ago by Sir Douglas Black (Dept of Healthand Social Security, 1980), this reports recommendations have been carefullyexpressed to reflect the current government agenda, and it has been published andpublicised in a generally supportive way by the Department of Health. National

Priorities Guidance for Health and Social Services (Dept of Health, 1998(b)) hadalready anticipated the report, by including the reduction of health inequalities as ashared priority. There has, however, been no formal government response as yet toAchesons recommendations: this may be expected to emerge in developing policyover the next few months partly in the White paper, expected early in 1999, toprogress Our Healthier Nation (Dept of Health, 1998(c)), but to a much greaterextent in the wider range of economic, fiscal and other policy areas.

Independent Inquiry into Inequalities in Health: Terms of Reference

1. To moderate a Department of Health review of the latest available information oninequalities of health, using data from the Office for National Statistics, the Department of Health and elsewhere. The data review would summarise the evidence of inequalities of health and expectation of life in England and identify trends.

2. In the light of that evidence, to conduct within the broad framework of the Governmentsoverall financial strategy an independent review to identify priority areas for future policydevelopment, which scientific and expert evidence indicates are likely to offer opportunitiesfor Government to develop beneficial, cost effective and affordable interventions to reducehealth inequalities

3. To report to the Secretary of State for Health. The report will be published and itsconclusions, based on evidence, will contribute to the development of a new strategy forhealth .


8/43


9/433

3. 4 Finally, recommendations are made for principles and practice inThe National Health Service : Equitable access to effective care in relation to need (37) More equitable allocation of resources (38) Equity profiles and progress audits (39)

3.5 The recommendations are a mixture of the broad-based and the specific; andinclude broad-based or upstream, as well as more direct or downstreammeasures to alleviate inequalities. Apart from the 3 main priorities, which areamong the most large scale, there is no prioritisation: the proposals arepresented as a portfolio, with many cross-referenced as addressing more thanone aspect of health inequalities, and cherry-picking specificallydiscouraged. Costing of the proposals was explicitly excluded from theInquirys terms of reference, leaving implementation to be addressed at thepolitical level.


10/43


11/435

Demographic determinants: A relatively young and mobile population The UKs most ethnically diverse city: almost half UKs ethnic minorities

live in London

Geographical variations: Inner London is worst off for some of the above - though its boundaries

differ between variables Differences between East and West London for some variables

Access to services: Better access to secondary and tertiary acute services the latter

acknowledged by Acheson to place demands (for critical mass) sometimesinconsistent with equity of access

Relatively poor access to primary care, especially in the more deprivedareas.

3. MEASURING INEQUALITY IN LONDON

3.1 Given the renewed significance given by Acheson and others to healthinequalities, this section considers the extent to which we can measureinequality. In developing an understanding of health inequality that links toour local health agenda there are three key barriers to overcome:

1. Many of the observations in the literature (and used by Acheson) are basedon national data-sets and look at health differences between differentsocial groups (variously defined e.g. social class, unemployed, ethnicstatus etc.). There are relatively few instances where similar data areavailable at a local level. However we do have data available forgeographic areas within districts most commonly wards (populationsaround 5-10,00).

2. There is no consensus on how we measure inequality itself or how weassess if it is improving (or deteriorating). A number of relativelysophisticated measures exist, such as a Gini coefficient, but these can bedifficult to interpret and understand. A recent review paper discussed 12different summary measures of inequality (Mackenbach & Kunst, 1997).

3. In this context, the term inequality can be used inter-changeably fordifferences in :

- health status itself - the socioeconomic determinants of health e.g. housing, income- lifestyle and health related behaviour- the quality of health (and welfare) services, in particular access toservices.


12/436

3.2 Differences between districts/boroughs within London.

HoLP analyses have commonly used borough by borough comparison of basichealth indicators (Bardsley & Morgan, 1997). These show the generallyexpected pattern that some inner London boroughs tend to be consistentlyworse on almost all health and social indicators when compared to moreaffluent areas. Figure B1 gives a typical example of the scale of differences

within London. Premature mortality rates (in this case based on StandardisedMortality Ratios under age 75- SMRs) range from at best about 20% betterthan UK average, to around 30% worse. This range encompasses the bestand the worst boroughs in the UK in terms of premature mortality rates.

Figure B1. Differences in SMR (ages


13/437

3.3. Differences within districts/boroughs

It is possible to look at some health status indicators at ward level and link these to economic and social characteristics of the wards. Inequalitiestherefore become expressed in terms of the health differences betweenpopulations in the richest and poorest areas of the borough.The advantages with this type of approach are: it enables some quantification of inequality at a local level there are some data about the ward label, and description, can often be a useful means of

communication between agencies and can generally be understoodthroughout the district

The disadvantages include: the danger of the ecological fallacy i.e. assuming that characteristics of

the ward population necessarily apply to every individual; the danger of focusing on poorest areas, yet neglecting to see poor

individuals living within relatively affluent wards; the numbers of events e.g. deaths can be small within any one ward so

there will be a high degree of statistical uncertainty about the observedvalues in any one year. To overcome this problem, multiple years of datacan be used, but this makes time series analysis more difficult. Wards canalso be grouped, say on the basis of deprivation;

the denominators, in terms of ward populations, have to be based onestimates in inter censal years. This in itself may introduce some elementof error.

Mortality data are available in abundance, and when linked with estimates of ward level populations can provide health status indicators such as prematuremortality rates.

The following sections describe some different analyses of mortality rates atward level.

3.4 Comparing the Distribution of Health Status across Wards

In this case, inequality in observed health status is being measured by lookingat the distribution of ward values of mortality rates (SMR under age 75) withina borough. Greater inequality is shown by a larger difference between wards irrespective of the absolute level of health or ill-health.

Within any one borough there may be 20-30 wards, each with its own SMRvalue. Figure B2 shows individual ward values for the 33 London boroughsbased on data from 1996. This gives an indication of the spread of valuesbetween wards- compare for example Greenwich with Enfield or Hackney.Boroughs with many wards with small populations are more liable to showextreme values.


14/438

There are different ways of summarizing these distributions. One approach isto compare the extremes of the distribution by looking at the differencebetween the most and least healthy wards within the borough (Table B1)


15/43

9

Figure B2 Individual ward scores for SMR under 75 by borough

SM Rs (


16/43

10

Table B1 Comparing differences in SMR (


17/43

This method has the advantage that it can account for differences in thenumbers of wards in a borough and is better suited when the size of wards issmall. Table B1 shows the values and the confidence intervals for the

aggregated SMRs for the three highest and three lowest wards in eachborough. For all boroughs the aggregate of the three highest wards is abouttwice that in the three lowest wards. The table also shows that thesedifferences between the top and bottom ends of the range are statisticallysignificant in all boroughs.

Though this method is simple it does concentrate on the ends of thedistribution. The danger is that values for individual wards, particularly oneswith small populations, may be statistically unreliable. On the other hand itmay be argued that we are more interested in the extremes of values, asindicators in inequality, than the bulk of the distribution in the middle.

Though differences in standardised mortality ratios can look dramatic, it isimportant to recognise the underlying numbers of deaths linked to theserelative rates. Across London in 1996 there were over 26,000 people whodied under the age of 75, only about 20% of these deaths were in the fewwards with the highest SMRs. Though geographic analyses of differences inhealth status can be valuable in thinking about targeting resources andpriorities, at the same time we have to recognise that ill-health is not restrictedto a few localities. Different methods of measuring and identifying healthinequalities need to be considered in tandem with these simple geographicapproaches

Table B2 Classifying boroughs by distributions of ward level SMR and medianSMR for boroughs

MedianSMR 38-50 52-64 70-115

Harrow Redbridge Kensington and ChelseaBromle Bexle

Low Barnet EnfieldKin ston u on Thames Richmond U on Thames

SuttonMerton Croydon Newham

Medium Waltham Forest Havering WestminsterHounslow Camden Haringey

HillingdonEalinBrent

Wandsworth Islington GreenwichTower Hamlets Lambeth Lewisham

High SouthwarkHammersmith and Fulham

HackneyBarkin and Da enham

Range in ward level SMRs (range 10th-90th percentile)

The values describing the distribution of health are independent of theabsolute levels of SMRs. Table B2 compares the median SMRs for wards in a


18/43

Hamlets are boroughs with high SMRs, yet when compared to other boroughsthey have relatively less difference between wards. The choice of measurethat we use to quantify the variability may potentially affect the results

though in this case some alternative measures, based on inter-quartile distanceor the standard deviations of the distribution, produce broadly similar results.

When looking at Table B2 it is important to be aware of some of thelimitations of this approach. Firstly, even in those boroughs where there isrelatively less variability than in others (the top left cell of Table B2), there arestill large and significant health inequalities between wards. For exampleFigure B3 shows the range of SMRs for the individual wards within these fiveboroughs, and demonstrates that, even within these relatively healthy areas,there are clear and significant health inequalities between wards on this healthindicator.

Figure B3. Profile of individual ward-level SMRs for five boroughs .

20

40

60

80

10 0

12 0

14 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Ward rank in borough

Barnet Bromley Harrow Kingston upon Thames Sutton

Secondly these results are based on one health indicator, i.e. mortality belowthe age of 75. There are some other indicators that that could be used in thesame way and give slightly different results. For example Table B3 is basedon a grouping of boroughs according to the distribution of limiting long termillness at ward level. Once again the variability within a borough is based ondifference between the 10 th and 90 th percentile values of wards using anindirectly standardised value for limiting long term illness (England & Walesvalue=100).

The fact that there are differences between Tables B2 and B3 is a reminderthat different health indicators provide slightly different views of health status,and in this case of health inequalities.


19/43

Table B3. Classifying boroughs by the distribution of wards according to levelsof limiting long term illness .

MedianValue LTI 14-30 31-38 38-68

Harrow Merton Kensington and Chelsea70-84 Barnet Bromley Westminster

Kingston Sutton HaveringRichmond Bexley

Wandsworth Croydon Brent84-105 Hounslow Waltham Forest Newham

Hillingdon EalingHammersmith and Fulham Enfield

RedbridgeLambeth Lewisham Haringey

Barking and Dagenham Southwark Camden105-134 Islington Greenwich

HackneyTower Hamlets

Difference between 10th and 90th ercentiles

4 TRENDS AT WARD LEVEL WITHIN BOROUGHS

We can extend the cross-sectional analysis of SMR to look at trends at wardlevel within boroughs. Most of the differences observed at the individualborough level with this very simple approach are not statistically significant.Nevertheless the analysis gives a pointer to some of the patterns of change thatmight be important locally.

Table B4 compares the aggregated SMRs (ages under 75) in 1981,1991 and1996 for the three wards in each borough with the lowest and highest SMRsat that time. The gap between the highest and lowest values is also shown ateach point in time. The results show the gap to have increased between 1981and 1996 in all boroughs except one (Hounslow). Though the scale of theincrease is different, the results are surprisingly consistent.

Within any one borough this increase in the gap in SMR between highest andlowest wards may be the product of either an improvement in the healthiestwards (i.e. the best getting better) and/or deteriorating relative health in theleast healthy wards (i.e. the worst becoming worse).

Table B4 table also shows a ratio of the SMRs in 1996 and 1981 as a roughguide. In almost all boroughs the highest value SMRs have tended to increase(with the exception of Ealing) with the greatest increase being over 30%.Comparing the three wards with the lowest SMRs, the picture is more mixed,though in the majority of cases the SMRs in 1996 are lower.

NB The comparison of SMRs in this way is a little tricky remember these

are relative mortality rates against a background of falling absolute values. Itmay be that part of the observed increase in the different between highest andlowest SMRs is a consequence of expressing the same basic difference in


20/43

14

Table B4 Summary of trends in healthiest/unhealthiest wards

Comparing SMR (age under 75) picking out highest and lowest three wards at each point

Highest Difference between highest and low1981 1991 1996 Ratio 96/91 1981 1991 1996 Ratio 96/91 1981 1991 199

Barking and Dagenham 90 86 83 0.92 137 159 164 1.20 47 73 Barnet 64 63 63 0.97 96 109 110 1.15 32 46 Bexley 68 70 54 0.79 113 115 122 1.08 45 45 Brent 69 65 63 0.91 130 145 145 1.12 61 80 Bromley 67 64 55 0.82 115 111 119 1.04 47 46 Camden 73 69 70 0.97 136 138 152 1.11 64 69 Croydon 67 71 57 0.86 114 117 139 1.22 47 46 Ealing 85 79 71 0.84 152 139 144 0.95 67 61 Enfield 55 57 123 137 0 68 Greenwich 59 67 41 0.70 151 170 198 1.31 93 103 Hackney 94 98 70 0.75 136 156 153 1.13 42 57 Hammersmith and Fulham 91 78 82 0.90 134 157 184 1.37 43 79 Haringey 85 72 67 0.79 124 129 156 1.26 40 57

Harrow 71 60 57 0.80 100 97 104 1.05 29 38 Havering 64 67 61 0.95 109 115 132 1.21 45 48 Hillingdon 64 70 61 0.96 108 123 161 1.49 44 53 Hounslow 70 78 85 1.22 127 126 139 1.10 57 48 Islington 80 96 90 1.12 129 142 171 1.33 48 46 Kensington and Chelsea 72 56 56 0.77 139 158 181 1.30 66 101 Kingston upon Thames 62 64 55 0.89 102 121 110 1.08 39 56 Lambeth 90 96 91 1.02 137 153 170 1.23 48 56 Lewisham 74 83 81 1.09 125 138 173 1.38 51 55 Merton 73 65 67 0.92 112 115 117 1.04 39 49 Newham 90 97 91 1.01 137 161 186 1.36 47 64 Redbridge 69 64 59 0.85 116 124 118 1.01 47 60 Richmond Upon Thames 74 67 49 0.66 105 110 115 1.10 31 43 Southwark 87 94 77 0.89 134 153 166 1.24 47 60 Sutton 60 62 60 1.00 105 114 132 1.25 45 52 Tower Hamlets 99 104 103 1.04 143 139 170 1.19 44 35 Waltham Forest 73 80 81 1.10 112 131 136 1.22 39 52 Wandsworth 82 91 83 1.02 141 141 149 1.06 59 50 Westminster, City of 74 56 48 0.65 143 143 151 1.06 68 87

Lowest


21/4315

5. TRENDS IN HEALTH AND DEPRIVATION BY WARD ACROSSLONDON

5.1 Many studies have pointed to the strong and enduring relationships betweenhealth indicators such as premature mortality and measures of socio-economicstatus or deprivation (Eames et al, 1993). Figure B1 showed the relationshipsfor boroughs. A similar pattern holds at ward level, though the variability

between wards is greater as the numbers are small. This relationship existswithin boroughs and is visible in some of the most affluent parts of London.Figure B3 shows for the five boroughs used earlier, the relationship betweenSMR in 1991 (aged under 75) and the Jarman Under-Privileged Areas (UPAscore).

Figure B3. SMR


22/4316

The comparison between 1981 and 1991 usefully links in with census years-however it was considered worthwhile attempting to update this work.Extension to 1996 is complicated by a number of factors.

1. There have been major changes in ward boundaries since 1991 and 1996.To overcome this, all wards where there had been major changes (as

notified by ONS) were excluded. As a result the comparisons would haveto look at 543 rather than 727 wards in the earlier analysis. A check on theresults from 1981 to 1991 on this subset of wards in 1996 however showedalmost exactly the same results as the earlier analysis.

2. Population estimates are calibrated at the census years. For interveningyears ward based estimates need to be used these may be drifting awayfrom the real populations.

3. The potential for changes in the level of deprivation at ward level isgreater over a longer time period. A classification of wards based on theposition in 1981 may place wards in groupings that are not relevant by1996.

Using exactly the same approach as before, i.e. grouping wards in quintiles onthe basis of 1981 DoE ILC produced some interesting results (Table B5).

The extension of the analysis to include 1996 data shows how the differencebetween the least and most deprived quintiles continues to increase in London.Comparing 1981 with 1996, for the least deprived fifth of London wards theSMRs have moved from 80.2 to 82.6, whilst for the most deprived wards thechanges were from 113.7 to 130.6. These changes are in relative mortality,against England & Wales and at a time when the aggregate SMR for Londonhas been increasing.

Table B5: Changes in SMRs(age


23/4317

5.3 It may be that these differences are statistical artifacts. Alternatively it may bethat changes in the wards themselves, or in the ward populations have beensignificant over this 15 year period. The classification above is based on anordering as at 1981 wards may have changed in character over that time.One simple way of looking at this is to compare the ordering of wards at thetwo time points.

Unfortunately we do not have the same measure of deprivation, and have toassume that they act in the same way. Table B6 shows the change in SMRfrom 1981 to 1996 according to the level of deprivation (in three bands) on theDoE index of 1981 and the latest DETR index of 1998.

This table shows that using this crude classification, the ordering of wards in1996 is pretty much the same as in 1981 for 451 of 543 wards (83 per cent).Comparing the wards that have stayed in the same banding (the diagonal cellsin the table) the pattern is consistent with that above. Wards in the leastdeprived bands at both times have moved relatively little from 82 (CI:80-84)to 87 (CI:85-89), whilst for those wards consistently in the most deprived band

the change has been far greater: from 112 (CI:110-114) to 126 (CI:123-129).

Table B6 Changes in SMR (age 87 91 => 102

Rank on 80.4 - 84.1 84.6 - 89.2 85.9 - 97.0 95.0 - 109.9

deprivation n = 19 n = 135 n = 27

in 1981 (1) Average 93 => 95 98 => 108 103 => 11487.1 - 98.4 87.9 - 102.3 95.6 - 100.3 104.8 - 111.0 97.8 - 108.2 107.4 - 121.4

n = 27 n = 154

Most deprived 110 => 126 112 => 126103.8 - 116.3 117.8 - 134.5 109.7 - 114.5 123.1 - 129.5

(1) Based on DoE Index of Living Conditions 1981

(2) Based on DETRIndex of deprivation 1988

No. of wards

SMRs 1981->1996

95%CIs

6. CONCLUSIONS

1. These analyses are intended to illustrate what can be done using ward leveldata. They also help to explore some of the key issues that need to beconsidered when developing indicators of inequality.

2. Looking at inequality in health status, the London-wide picture reveals thestriking differences between areas within the city. An alternative view isto consider variation within areas, such as boroughs.


24/4318

3. There are few consistent data points that can be used to translate nationalwork on inequality to local work. In practice it is most likely that manylocal assessments of inequalities will be linked to either specific local datasets, such as health and lifestyle surveys, linked to specific areas e.g.wards, housing estates, or certain client groups e.g. ethnic minorities,young mothers etc. The most likely areas for describing the extent of

inequality using local data are through small area variations typicallyusing ward data. This is relatively easy examples are given. Yet it mayalso be misleading and is not the only approach that should be adopted.

4. Ranking areas according to ward level variation in SMR or limiting longterm illness, presents a different view of health inequalities acrossLondon. A view of which areas of London include the greatest inequalityis different from a simple map of health status. There are no standardmethods of measuring inequality. Local areas will have to considercarefully the methods they use and the appropriateness of the approach.

5. Trends in SMR for healthiest and least healthy wards within boroughs areexamined, and show how the gap has increased over 15 years. This is aproduct of both the lowest SMRs getting lower and the highest SMRsgetting higher.

6. Changes in SMR for wards across London, classified by the level of deprivation show a pattern of an increasing divide between the least andmost deprived wards (as defined by 1981 deprivation index).

7. These are preliminary analyses. The approach could be easily extended toinclude some other health indicators, e.g. limiting long-term illness, infant

mortality. Similar methods could be applied just to looking at some of theward level data on determinants of health. More sophisticated analyticalmethods could also be used. For example:

- Inequalities in health status versus inequalities in determinants of health?- Geographic inequalities versus difference between specific social

groups?- Inequalities within our own area or in relation to elsewhere.- Inequalities in the extremes of health experience in smaller areas (as

when looking at deaths) or in smaller differences between larger areas.


25/4319

SECTION C: IMPLICATIONS OF THE REPORT AND ITSRECOMMENDATIONS FOR HEALTH AUTHORITIES AND OTHERS INLONDON

1. LONDON CONTEXT

The report comes at a time of renewed identity and structural change in

London, both for the NHS and for local and Regional government.

1.1 The new London Regional Office of the NHS Executive is now responsiblefor the 16 Health Authorities covering the former Greater London Councilarea: this is the first time that NHS structures have reflected this geography.As elsewhere, Primary Care Groups of varying sizes are coming into effectfollowing The New NHS (Dept of Health, 1997); while the London HealthAuthorities are beginning, for some purposes, to work together, as proposedby Turnberg, (Dept of Health, 1997 (b) in the five sectors broadlyassociated with each medical school, and which extend from inner to outerLondon.

1.2. At the same time, the draft Bill to establish a Greater London Authority(GLA), comprising an elected Assembly and a separately elected Mayor, hasbeen published and is being considered by Parliament in its current session:this is now expected to lead to the establishment of the GLA from autumn2,000. This will mean some changes in the responsibilities now exercised bythe 33 local authorities, and more in those of the Government Office forLondon, and of a number of other government departments and public sectoragencies. The GLAs responsibilities, insofar as they can be assumed fromthe draft legislation, are summarised at Appendix C: they include strategiesaffecting many of the determinants of health, while specifically excluding

health services. However the re-introduction of a directly elected pan-Londonbody, with an inevitably high-profile mayor, has raised expectations of London-wide action and influence beyond these formal responsibilities.

2 ACHESONS OVERALL APPROACH TO INEQUALITIES, AND THEKEY PRIORITIES

2.1 The report focuses primarily on health outcomes, and on the economic, social,behavioural and demographic determinants of health. Most of the proposedactions would address health outcomes by either reducing inequalities in thesedeterminants, or by making special provision to meet those disadvantaged by

difference. Inequities in access to health services are outlined, linked torecommendations for the NHS to pursue equity in the provision of services inrelation to needs, and in resource allocation.

2.2 The main message of the report is that the current inequalities in health areexcessive, are undesirable, and should be reduced. There is no explicitsuggestion that this should be pursued by means which include any element of levelling down: rather, improvements in the position of the worse off aresuggested.


26/4320

2.3 To date, many inequalities-related initiatives of the current government havebeen addressed through the Social Exclusion Unit and the identification acrossthe country of small, multiply deprived groups for example specific housingestates, multiply disadvantaged children, low income smokers within HealthAction Zones. Some of Achesons recommendations could be interpreted in asimilar way, suggesting a focus on, for example, the most disadvantagedcommunities, or disadvantaged families, or homeless people. However its key

priority recommendation to further reduce income inequalities, and improve the living standards of households in receipt of social security benefits , has afar broader application.

2.4 It also has substantial cost implications. The Inquiry has not engaged in anyelement of costing of its recommendations. Given that the health gain, and sopotential reduction in treatment costs, arising from these recommendations islikely to be medium to long term rather than immediate, they will depend forimplementation on economic circumstances and fiscal policy as well aspolitical commitment. For London, the capitals prosperity, as well as theextent of redistribution of public sector funding in general to other parts of the

country, will impact on the eventual outcome.

2.5 An issue for London, which will be reflected to a varying extent in the otherregions in England, is the level at which reduction in inequalities is pursued:are targets to be set at national, Regional or more local level, and will they berelative or absolute? It is important that Governments response is explicit onthese points. National Priorities guidance stresses the role of HealthAuthorities and Social Services in addressing some very specific areas, butalso the role of Primary Care Groups in local primary/community servicedevelopment and in improving service access. The analyses at Section B showthe extent and direction of some health inequalities at ward and borough level

in London, and demonstrate that reducing inequality between boroughs orHealth Authorities cannot be the only priority in terms of equity acrossLondon, when inequalities within them are so great. The basis of the five NHSsectors, which each combine inner city with outer areas, means thatinequalities within some of them will exceed to an even greater extent thedifferences in average levels between sectors.

2.6 In relation to the priority population groups of women and young childrenand people dependent on benefits, London has (compared with England andWales) above-average conception rates but also far higher termination rates; asimilar proportion of children in the population, but more children living in

overcrowded and temporary accommodation, in lone parent families and withother indications of poverty; fewer people of retirement age and with lowermortality in that age group. There are wide variations in some of thesebetween parts of London. If future policy development and resourceallocation shifts, were linked to these particular groups, London overall mightnot gain, though some areas within it would at the expense of others.

2.7 In the same way population groups not specifically prioritised by the Inquirycould lose out in any such shift of policy and resources: these include peoplewith physical and learning disabilities traditional priority care groups for


27/4321

the NHS, but not specifically noted in the Inquirys findings orrecommendations.

2.8 As a means to support substantive recommendations, the assessment of theimpact of all policies on health inequalities is proposed as the first of theInquirys main priorities. This is a special case or aspect of the process - notyet heavily used across the UK, but growing in its application of health

impact assessment . An area where health impact assessment has beenproposed locally is in respect of the GLA: the White Paper A Mayor andAssembly for London stated that the Authority would be responsible forconsidering the broad health implications of all the GLAs policies (Dept of Environment, 1998). The scale and mechanics for the future GLA inexercising this responsibility less clearly expressed in the GLA Bill are atthis stage far from clear: and the extent to which health inequalities areincorporated in such analysis could clearly be subject to the Mayor andAssemblys political perspective . It is important for both the academic andservice-linked sectors in London, which are the potential resource for thiswork, to consider how this recommendation could best be met.

3. RECOMMENDATIONS AND WHO MIGHT IMPLEMENT THEM

3.1 The agencies which would be responsible in London, post-GLA, forimplementing the individual recommendations are suggested at Appendix B.At national, regional/pan-London and local levels, there are few which relateto only one agency or sector, and far more which require inter-sectoralcollaboration.

3.2 As indicated above, very many of these recommendations can only beaddressed by national government policy and action . This applies to issues

of: Social Security Benefits - maintenance or increase of levels. Prioritization of specific population groups - ensuring this happens across

sectors. Adjustment of resource allocations in the public sector proposed for

Revenue Support Grant in relation to schools, as well as NHS resources. Legislation and regulatory frameworks school nutrition policies; health

and safety, employment requirements; housing regulations; food contentregulations; fluoridation; tobacco advertising and other restrictions; duty of partnership between separate agencies where required.

Influence on pricing through fiscal measures alcohol, tobacco.

3.3 Some of the above would require action of specific national governmentdepartments and agencies: Benefits Agency social security uptake DfEE education and employment measures Health and Safety Executive and Trade Unions improving health at

work DETR regeneration, housing, environmental improvements including

motor vehicle emissions; water fluoridation;


28/4322

MAFF Common Agricultural Policy surplus food scheme; Food Standards Agency when established; Department of Health: promoting improvements in day care and social

support for families; health promotion through the Health EducationAuthority; incorporating equity issues into The New NHSimplementation; NHS resource allocation.

3.4 London wide implementation would depend similarly on commitment andaction by political as well as administrative bodies. Relevant agencies includethe GLA itself, and others with accountability to it, specifically: London Development Agency Metropolitan Police Transport for London London Research Centre (or successor organisation).

Within the NHS, the London Regional Office of the NHS Executive is wellplaced in geographic terms to relate to these agencies: however in some casesit is not clear whether its functional responsibilities, rather than those of Health Authorities collectively, make it the appropriate partner; and acoordinating and monitoring role may be more appropriate. If partnershipwith the GLA is a requisite as Achesons final recommendation suggests -then this will need to be a requirement on both sides, and to be incorporated inthe GLA Bill.

3.5 At the local, sub-London level relationships are more complex and alsovariable.

3.5.1 Major players include Health Authorities , which would be expected toidentify local inequalities targets, as well action to meet national ones, throughtheir Health Improvement Programmes.

3.5.2 Many recommendations would also require action on the part of Local Authorities (London boroughs and the Cities of London and Westminster) ,specifically those relating to education, housing, social services, leisure andlocal planning. Of these, education measures need also to be addressed byindividual schools including the grant maintained, voluntary and privatesectors - as well as LEAs; while housing measures are also the business of the voluntary sector, especially Housing Associations, and private rental andowner occupiers; and both require collaboration with other agenciesincluding the NHS. In respect of social services, the requirement for the NHSand social services to collaborate on cutting health inequalities has alreadybeen identified as a shared priority for the next three years.

3.5.3 As Londons HAs comprise between one and four local authorities; and giventhe varying size, shape and functional levels of the Primary Care Groupswhich they have established, the roles of PCGs and HAs in implementingthese recommendations are likely to vary between places and over time. SomePCGs relate geographically though not exactly in population terms - to oneor two whole local authorities; many cover part of a borough, while some


29/4323

cover parts of more than one. Their role in cutting health inequalities and inimproving primary healthcare is stressed in National Priorities Guidance.

3.5.4 As PCGs become Trusts their responsibilities in this as in other directions arelikely to increase; while individual GP practices and other trusts would beexpected, as NHS providers , to address especially the issues of equity inaccess to services and, like all employers, the quantity and quality of available

employment.

3.5.5 Other relevant local bodies and individuals within London, but working todifferent boundaries from Health Authorities, include: Training and Enterprise Councils Probation and Youth Justice services Members of Parliament, Members of European Parliament GLA members Tertiary academic institutions , including nursing and medical schools Private sector general and health-related Voluntary organisations though a number of these are, or relate to,

borough-based or Greater London groupings Families and individual Londoners Multi-agency partnerships including Health Action Zones.

4. CONCLUSIONS AND KEY ROLES FOR HEALTH AUTHORITIES INLONDON

4.1 Achesons key recommendations require central government commitment, andcentral leadership to ensure implementation. The content of the White Paperon Our Healthier Nation should give some indication of the commitment toprioritising mothers, children and families and to assessing the impact of policy in terms of health inequalities; however resourcing the latter process,and even more, the suggested improvements in broad-based benefits throughtaxation changes, will take longer to agree and implement.

4.2 Meantime, Health Authorities in London should expect to respond in terms of the following:

1. Action for which the NHS, and HAs in particular, are responsible: HealthImprovement Programmes; Health Promotion; consultation on fluoridatingthe water supply.

2. As employers, promoting healthy employment and transport policies.3. Developing effective partnerships with other agencies: in education,

housing, criminal justice, transport and the environment, social services,private and voluntary organisations as well as their residents within theperformance management framework to be agreed with the LondonRegional Office.

4. Influencing and promoting the reduction of health inequalities at nationaland regional level through the wider policy agenda.

5. Understanding and accommodating resource reallocation in relation toGeneral Medical Services, and to reviews of the pace of change policy,


30/4324

HCHS formula and deprivation payments, and the contribution of privatepractice.

6. Promoting equity of access to effective health care.7. Producing equity profiles; developing and then monitoring joint

programmes, in partnership with local authorities and others, by assessingtheir impact on inequalities in health.

N:\cl\acheson415 04 99


31/4325

REFERENCES

Anderson H and Flatley J (1998) Contrasting London incomes. London: LondonResearch Centre

Bardsley M & Morgan D (1996). Health Chapter 4 in: Edwards P & Flatley J (Eds).The capital divided: Mapping poverty and social exclusion in London . London:

London Research Centre.

Bardsley M & Morgan D (1997). Deprivation and health in London: An overview of health variations within the capital. The London Journal , 22 : 142-159.

Department of the Environment, Transport and the Regions (1998). A Mayor and Assembly for London. Cm. 3897. London: HMSO.

Department of Health (1997) (a). The New NHS: Modern Dependable. Cm 3807.London: HMSO.

Department of Health (1997) (b). Health Services in London A Strategic Review.London: HMSO.

Department of Health (1998) (a). Independent Inquiry into Inequalities in Health Report. London: HMSO.

Department of Health (1998) (b). Modernising Health and Social Services: National Priorities Guidance 1999/00 2001/02. London: HMSO.

Department of Health (1998) (c). Our Healthier Nation: A Contract for Health. Cm3852. London: HMSO.

Department of Health and Social Security (1980). Inequalities in health: The Black Report . London: HMSO.

Eames M, Ben-Shlomo Y & Marmot MG (1993). Social deprivation and prematuremortality: Regional comparison across England. British Medical Journal , 307 : 1097-102.

Health of Londoners Project (1998). The Health of Londoners: a public health report for London. London: Kings Fund.

Mackenbach J and Kunst A (1997). Measuring the magnitude of socio-economicinequalities in health: An overview of available measures illustrated with twoexamples from Europe. Soc Sci Med 1997;44:757-771

McLoone P & Boddy FA (1994). Deprivation and mortality in Scotland, 1981 and1991. British Medical Journal , 309 : 1470-4.

Phillimore P, Beattie A & Townsend P (1994). Widening inequality of health inNorthern England, 1981-91. British Medical Journal , 309 : 1125-8.


32/43


33/43

27

INEQUALITIES IN H EALTH ACHESON R EPORT : F INDINGS FOR E NGLAND P OSITION IN Health StatusGeneral Trends Death rates down (100y)

Life expectancy but not healthy life expectancy - up;More limiting longstanding illness (20y)

Mortality (trends) Mortality falling and life expectancy rising more forhigher social classes (20y) a bigger divide

A less rapid Bigger gap (wardsInner Londomen

Years of life lost Premature mortality from major causes higher in lowersocial classesInfant mortality decreasing, but the class divide is not

Similar to otvariations

Morbidity Class divide in self-reported longstanding illness mostage and gender groupsObesity is rising(3y); bigger class divide in women thanin menBlood pressure: class divide for women onlyMajor accidents: variable class difference in someage/gender groupsMore neurosis in lower classes women

More alcohol & drug dependence in lower than higherclass men

Similar patte

Unclear.

? (Health S? For RTAsbike and moMental HealCaribbean mHigh rate ofdeprived areHigher incidincluding HIHigher incidTB


34/43

28

INEQUALITIES IN H EALTH ACHESON R EPORT : F INDINGS FOR E NGLAND P OSITION INSocial DeterminantsIncome distribution Median incomes have grown (30y); but much more for

top percentiles than for bottom percentilesLondon has extreme (low

Households below averageincome

Proportion below half average income doubled (30y) to1991, down a little since then

Higher propcentral and E

Education School attendance by 3-4 yr olds up but variable(25 y)

GCSEs up , but variable (20y)

Workforces educational attainments variable(gender/ethnic group)

Similar LA pEngland; priMost borougborough var15% low/venumeracy; w

Employment Unemployment up (30y) and variable by class

Youth unemployment up (5y)Ethnic /gender variations

Unemploym

increasing aouter Londo

Highest in yHousing Dwellings up, tenure shift (60y)

More 1-person householdsHousing stock conditions variable

Higher propAssociation England. W?Typical (for

Homelessness Acceptances up 82-92, then down Similar: declineEstimated nu237,000


35/43

29

INEQUALITIES IN H EALTH ACHESON R EPORT : F INDINGS FOR E NGLAND P OSITION INPublic Safety Crime rate *3 (25y)

Variations per type of areaVariations in type

Crime rate t

Top for frauTransport Increased car ownership (24y)

Car ownership linked to economic activity, tenureTravel to work method urban-rural differences

Outer Londolevels of accLondon 46%Similar assoindicatorsTransport, inimpacts

Health related behaviour Smoking down (20y); alcohol unchangedLower classes smoke more than professionals

Higher class women drink more than lower class womenExercise: lower class men do more at work

Lower class people eat less fruit, vegetables, fibre,vitamins & mineralsLower classes breastfeed less differential slightlynarrowed (10y)

Similar trenSimilar patte

Similar patteSimilar; Lonpeople than Similar patte

Demographic DeterminantsMinority ethnic groups Limiting longstanding illness differentials

Mortality - similar birth-place linked differentialsInfant mortality - differentials linked to mothers

birthplace

Most ethnic


36/43

30

INEQUALITIES IN H EALTH ACHESON R EPORT : F INDINGS FOR E NGLAND P OSITION INTrends in healthdifferences between thesexes

Mortality fall slightly greater for men (25y)Higher mortality for boys & young men

Healthy life expectancy only a little more for womenYoung males, older females have more serious accidentsMore girls smoke than boysMore males than females drink heavily

Mortality reIncreasing Hinner Londo

Similar alco Access to ServicesPrimary Healthcare Demand- and supply- linked variations

Communities needing preventive care most, have leastservices

Relatively pLeast GP he

Secondary Care Service use not always related to need Concentration o

Private sectoMental Health Services Service use linked to deprivationSpecific patterns in African Caribbean males and inAsian populationsPressure on inner city services

High inpatiePressure froLimited comAccess issuerefugees


37/43

31

Summarised Recommendations, and who might implement them in LondMain Recommendation Details of Recommendation Agencies to adGeneral Recommendations

1. That as part of health impact assessment, allpolicies likely to have a direct or indirect impacton health should be evaluated in terms of theirimpact on health inequalities, and formulated sothat, by favouring the less well-off, they willwherever possible reduce such inequalities.

1.1 Monitoring and evaluation

1.2 Review of data needs to improve capacity to monitorinequalities in health and their determinants at nationaland local level

1.1 Pa

1.2 I

2. A high priority should be given to women of childbearing age, expectant mothers and youngchildren.

All

Poverty, Income Tax and Benefits

3. That further steps should be taken to reduce

income inequalities, and improve the livingstandards of households in receipt of socialsecurity benefits

See also 8.1

3.1 Further reductions in poverty in women of child-

bearing age, expectant mothers, young children and olderpeople should be made by increasing benefits in cash or inkind to them.3.2 Uprating benefits and pensions to protect /improve thestandard of living of those who depend on them and narrowthe gap between their standard of living and average livingstandards.3.3 Increase uptake of benefits in entitled groups.

3.1, 3

3.3 Bsector

Education

4. Additional resources for schools servingdisadvantaged children. Revenue Support Grantetc.more strongly weighted to reflect need andsocioeconomic disadvantage.

Centra


38/43

32

Main Recommendation Details of Recommendation Agencies to ad5. Further develop pre-school education to meet,in particular, needs of disadvantaged families.

Evaluate benefits and if necessary provideadditional resources.

See also 21.1 LondoSocial

6. Further develop health promoting schools initially focused on disadvantaged communities.

LEAs

7. Further improving nutrition in schools: foodpolicies, budgeting and cooking skills, preservefree school meals entitlement; free school fruit,restrict less healthy food.

Centraprivat

Employment8. Improving opportunities for work, amelioratehealth consequences of unemployment.

8.1 Further steps to increase employment opportunities8.2 More training for young and long-term unemployedSee also 3, 21.1

DfEEfurtheAgenc

9. Improve the quality of jobs, reducepsychosocial work hazards.

9.1 Improve health through good management practices.

9.2 Assess impact of employment policies on health andhealth inequalitiesSee also 1

9.1 CeSafety9.2 In

Housing and Environment10. Improve availability of social housing ,taking account of social networks, access togoods & services.

LocalHousi

11. Improving housing and access to health carefor both officially and unofficially homelesspeople.

LocalServic

12. Improve the quality of housing 12.1 Improve insulation and heating to reduce fuel poverty.12.2 Amend conditions and regulations to reduce homeaccidents, including promoting smoke detector installation

CentraAssoc


39/43

33

Main Recommendation Details of Recommendation Agencies to ad13. Policies to reduce fear of crime and violence,

and create a safe environment.See also 3 Metro

systemcomm

Mobility, Transport and Pollution14. Improved, affordable and integrated publictransport system.

GLA

15. Encouragement for walking and cycling, safeseparation from motor vehicles.

GLA;

16. Reduction in car usage to cut mortality andmorbidity from motor vehicle emissions.

Centraemplo

17. Reduction in traffic speeds by roaddesign/modification, lower speed limits, stricterlimit enforcement.

GLA;

18. Universal high quality concessionary fareschemes for pensioners and disadvantagedgroups.

GLA

Nutrition and the Common Agricultural Policy19. Review of CAPs impact on health/healthinequalities

19.1 Strengthen CAP Surplus Food Scheme to improvenutritional position of less well off.

Centra

20. Increase availability and accessibility of foodstuffs to supply an adequate and affordablediet.

20.1 Ensure adequate retail provision of food to thedisadvantaged . See 3, 1420.2 Reduce sodium content of processed foods,particularly bread and cereals, without cost to customer.

RetailCentra

Mothers, Children and Families21. Enabling parents either to work, or to be full-time parents according to their wishes

21.1 Integrated policy for affordable, high-qualitydaycare/preschool education, extra resources fordisadvantaged communities. See 5

See also 3.1, 3.3

Centrasocial


40/43

34

Main Recommendation Details of Recommendation Agencies to ad22. Improving health and nutrition of women of child-bearing age and of children priority to

eliminating food poverty, preventing andreducing obesity.

22.1 Increase breastfeeding.22.2 Fluoridation of water supply.

22.3 Smoking cessation programmes before/duringpregnancy, focused on less well-off.

See also 3.1, 7, 19, 20.

22.1 H22.2 C

supplisharin22.3

23. Promoting social and emotional support forparents and children.

23.1 Develop health visitors to provide social /emotionalsupport to expectant parents, and parents with youngchildren.23.2 Local Authorities to identify and address health needsof looked-after children

23.1 Ceducaconso23.2 L

Young People and Adults of Working AgeSee also 8, 924. Measures to prevent suicide among youngpeople, especially young men, and the seriouslymentally ill.

HAs youth

25. Promoting sexual health in young people,reducing unwanted teenage pregnancy, includingaccess to appropriate contraceptive services.

HAs, (educa

26. Promoting healthier lifestyles, particularly infactors showing a strong social gradient.

26.1 Exercise: cycling and walking route to school, trafficseparation, safer opportunities for leisure.26.2 Tobacco: restrictions in public places,advertising/promotion ban, campaigns.26.3 Price increases, while improving living standards of

poor households.26.4 Nicotine replacement therapy on prescription26.5 Alcohol harm reduction, including price maintenance

26.1

26.2

26.3

26.4 26.5

Older People27. Improving material well-being. See 3, 3.2, 3.328. Improving older peoples housing. See 12.1, 12.2


41/43

35

Main Recommendation Details of Recommendation Agencies to ad29. Maintaining mobility, independence andsocial contacts.

See 13, 14, 18

30. Developing health and social services forolder people to be accessible and distributedaccording to need.

See 1.2

Ethnicity31. Specific consideration in development andimplementation of policies to reducesocioeconomic inequalities.

See 3, 8, 10, 12, 13, 14, 15, 16, 17, 18. All ag

32. Development of services which are sensitiveto needs, and which promote greater awareness of health risks.33. Specific consideration in needs assessment,resource allocation, health care planning andprovision.

See 1.2

Gender34. Reducing excess mortality from accidentsand suicide in young men. See also 24.

See 8, 11, 15, 16, 17, 26.5

35. Reducing psychosocial ill health indisadvantaged young women, especially thosecaring for young children.

See 3.1, 3.2, 3.3, 10, 14, 20, 21, 21.1, 22, 23, 23.1, 25

36. Reducing disability and its consequences inolder women, particularly those living alone.

See 3.1, 3.2, 3.3, 13, 14, 18, 28, 30


42/43

36

Main Recommendation Details of Recommendation Agencies to adThe National Health Service:

37. Providing equitable access to effective carein relation to need to be a governing principle.Priority to achievement of equity in planning,implementation and delivery of services at everylevel of the NHS.

37.1 Extending clinical governance to give equalprominence to equity of access37.2 Extend NICE remit to include equity of access37.3 Develop National Service Frameworks to address

inequities in access to effective primary care37.4 Performance management focussed on more

equitable access, provision and targeting to need inprimary and hospital sectors.

37.5 DoH and NHSE to set out their responsibilities forfurthering the principle; HAs, with PCGs andproviders through clinical governance, to agreeobjectives and priorities. Part of the HealthImprovement Programme

37.1 H

37.2 37.3

37.4

37.5

HAs,

38. Priority to more equitable allocation of NHSresources. Adjustment to ways of resourceallocation and to speed in which targets are met.

38.1 Review pace of change policy to enable HAs tomove more quickly to target.38.2 Extend needs weighting to General Medical Services

resources. Assess size and effectiveness of deprivationpayments.

38.3 Review size and effectiveness of Hospital andCommunity Health Services formula and deprivationpayments, consider alternative methods for focussinghealth promotion and public health care resources.

38.4 Review relationship of private practice to NHSparticularly access to effective treatments, resourceallocation, staff availability.

D o H

39. Directors of Public Health, on behalf of Health and Local Authorities, to produce anequity profile of population served, and triennialaudit of progress towards objectives reducinghealth inequalities.

39.1 Duty of partnership between NHS E and regionalgovernment to ensure effective local partnershipsestablished between Health, LAs and other agencies, and

joint programmes to address health inequalities are in placeand monitored.See also 1

39. D

39.1


43/43

Appendix C

GREATER LONDON AUTHORITY FUNCTIONS

The GLAs roles and functions are set out in the White Paper A Mayor andAssembly for London and in the Greater London Authority Bill. They will beexercised as follows:

Topic Pan-London, GLA-linkedbody

Mechanisms

Transport Transport for London (new)(London Regional Transportreplaced)

Transport strategy;

EconomicDevelopment

London DevelopmentAgency (new)

Mayor may appoint to LDALDA strategy

Environment London Biodiversity ActionPlan;Municipal waste managementstrategy;

London air quality strategy;London ambient noise strategy

Planning Spatial Development strategyMetropolitan Police Metropolitan Police

Authority (new)MPA includes Assemblymembers, nominated by theMayor and including deputymayor.

Fire Fire and EmergencyPlanning Authority(replacing Fire & Civildefence authority)

Culture, media, sport Culture Strategy Group Culture strategy;Mayoral appointments toresponsible bodies;work to attract high profileevents.

Health None Mayor must, in preparing,revising and implementingabove strategies, have regard to(among other issues) thedesirability of promotingimprovements in the health of persons in Greater London

Research andinformationcollection

Arrangements to succeedLondon Research Centre

Aches on Report

Documents

Transcript of Aches on Report