Policy approaches to health inequalities Policy approaches to health inequalities in Scotland and England in Scotland and England Assessing similarities and differences in post-Assessing similarities and differences in post-devolution policy responses to health inequalitiesdevolution policy responses to health inequalities

Dr Katherine SmithDr Katherine Smith

Katherine.Smith@ed.ac.uk

Global Public Health Unit, Social PolicyGlobal Public Health Unit, Social PolicySchool of Social & Political ScienceSchool of Social & Political Science

University of EdinburghUniversity of Edinburgh(ESRC-MRC postdoctoral fellowship, grant number PTA-037-27-0181)(ESRC-MRC postdoctoral fellowship, grant number PTA-037-27-0181)

Current concern: The failure of policy efforts to reduce Current concern: The failure of policy efforts to reduce health inequalities in Englandhealth inequalities in England

““Has the English strategy to reduce health Has the English strategy to reduce health inequalities failed? The importance of this question inequalities failed? The importance of this question cannot easily be overstated. The explicit and cannot easily be overstated. The explicit and sustained commitment of recent Labour sustained commitment of recent Labour governments to reduce health inequalities was governments to reduce health inequalities was historically and internationally unique […]. Their historically and internationally unique […]. Their policy initiatives built on decades of public health policy initiatives built on decades of public health research, and more often than not were based on research, and more often than not were based on empirical evidence which had been collected and empirical evidence which had been collected and summarized by leading public health experts. Labour summarized by leading public health experts. Labour stayed in power for an exceptional 13 years, and in stayed in power for an exceptional 13 years, and in Western democracies it is difficult to imagine a longer Western democracies it is difficult to imagine a longer window of opportunity for tackling health window of opportunity for tackling health inequalities. If this did not work, what will?” inequalities. If this did not work, what will?” (Mackenbach, 2010)(Mackenbach, 2010)

What do we know about post-devolution What do we know about post-devolution health policy in Scotland and England?health policy in Scotland and England?

Most analyses focus Most analyses focus eithereither on healthcare policies or on healthcare policies or on specific public health issues (e.g. health on specific public health issues (e.g. health inequalities or tobacco control). inequalities or tobacco control).

The story that emerges from this body of work The story that emerges from this body of work suggests healthcare policies have diverged suggests healthcare policies have diverged significantly (e.g. Greer 2005, Bevan 2010, Propper significantly (e.g. Greer 2005, Bevan 2010, Propper et et alal 2009, Connolly 2009, Connolly et alet al 2010)… 2010)…

… … whilst public health policies have remained whilst public health policies have remained remarkably similar, despite clear differences in initial remarkably similar, despite clear differences in initial intentions/rhetoric (e.g. Cairney, 2009; Smith intentions/rhetoric (e.g. Cairney, 2009; Smith et alet al 2009).2009).

Is Scotland Emerging as a UK Public Health Is Scotland Emerging as a UK Public Health Policy Leader?Policy Leader?

Interviewees across the UK are consistently Interviewees across the UK are consistently citing Scotland as a public health policy leader citing Scotland as a public health policy leader in the UK, following its leadership with smoke-in the UK, following its leadership with smoke-free public places and minimum unit pricing free public places and minimum unit pricing for alcohol.for alcohol.

Scotland now appears to have an opportunity Scotland now appears to have an opportunity to replace its tag as the ‘sick man of Europe’ to replace its tag as the ‘sick man of Europe’ with a new reputation for health policy with a new reputation for health policy innovation (e.g. Smith & Hellowell, 2012). innovation (e.g. Smith & Hellowell, 2012).

Yet Policy Approaches to Health Inequalities Yet Policy Approaches to Health Inequalities Remain Remarkably ConsistentRemain Remarkably Consistent

Aspect of policy approach England Scotland How were health inequalities conceptualised?

As health gaps resulting from health deprivation.

As health gaps resulting from health deprivation.

Commitment to joined-up approach?

Yes. Yes.

Reference to empirical evidence?

Yes. Yes.

Targets for reducing health inequalities?

Yes, specific health inequalities targets set in 2001, to be achieved by 2010.

Yes, specific health inequalities targets set in 2004, to be achieved by 2008/2010.

How were targets articulated? To reduce health gaps (mainly between areas).

To improve the health of the most deprived groups at a particular rate.

Where was responsibility for meeting health inequalities targets located?

Local NHS bodies (PCTs). Local NHS bodies (Local Health Boards).

The absence of evidence-based policy The absence of evidence-based policy in both contexts:in both contexts:

Senior academic researcher:Senior academic researcher: ‘The research [on health ‘The research [on health inequalities] has had absolutely no, well, it’s had very little inequalities] has had absolutely no, well, it’s had very little impact on policies,’impact on policies,’

Civil servant (England):Civil servant (England): ‘My impression is that after about ‘My impression is that after about 2001, unfortunately the sheer pace and scale of action 2001, unfortunately the sheer pace and scale of action required of the Labour government meant that evidence required of the Labour government meant that evidence again got pushed onto the back burner […] just because again got pushed onto the back burner […] just because government was producing more policies than it had time to government was producing more policies than it had time to master the evidence on.’master the evidence on.’

Minister (Scotland): Minister (Scotland): ‘I don’t think there’s very much evidence-‘I don’t think there’s very much evidence-based policy around yet.’based policy around yet.’

Taken from Smith, 2007, 2008.

Comparing the evidence to policy responses for Comparing the evidence to policy responses for tackling health inequalitiestackling health inequalities

Idea(s) about health inequalities Are ideas are supported by research evidence?

Are ideas are evident in Labour’s policies?

Artefact and social selection No No

Access to health services and treatments

Minimally Significantly (esp. from 2004 onwards)

Contextual (place-based) ideas Minimally Significantly (through area-based interventions)

Need to change people’s lifestyle-behaviours (L-Bs)

L-Bs are linked to HIs but are usually perceived to be symptomatic of more ‘upstream’ causes

Significantly (throughout the past decade but especially since 2004).

Material-structuralist Yes Significantly evident in policy rhetoric but far more limited with regards to policy actions

Psychosocial and income inequalities

Significant support (although some criticisms)

References to social capital are evident but reference to income inequalities are absent

Lifecourse approaches Yes A focus on particular social groups, especially children, is evident but ideas about the ‘lifecourse’ are scarce

1. Policymaking bodies as institutional filters1. Policymaking bodies as institutional filters

How Policy Silos Shape the Relationship with How Policy Silos Shape the Relationship with ResearchResearch

Civil servant (Scotland): Civil servant (Scotland): ‘People don’t go traipsing ‘People don’t go traipsing through professional journals but you do have through professional journals but you do have specialists within the Department as well. So, for specialists within the Department as well. So, for example, on diet and physical activity, there is a Diet example, on diet and physical activity, there is a Diet Co-ordinator, and there is a Physical Activity Co-ordinator, and there is a Physical Activity Coordinator, who are specialists in their own right… Coordinator, who are specialists in their own right… and in addition to that, you have specialists in terms and in addition to that, you have specialists in terms of doctors and things like, many of whom do actually of doctors and things like, many of whom do actually spend a bit of time with the journals.’spend a bit of time with the journals.’

2. A lack of belief in alternative ways of 2. A lack of belief in alternative ways of organising societyorganising society

A lack of belief in an alternative way of livingA lack of belief in an alternative way of living

Academic: Academic: ‘I think… a government that isn’t… ‘I think… a government that isn’t… keen to pursue issues around… income keen to pursue issues around… income redistribution… you know, that’s a reasonably redistribution… you know, that’s a reasonably popular thing to not do. Who wants to pay popular thing to not do. Who wants to pay more taxes? And… if taxes go up for the more taxes? And… if taxes go up for the richest, somehow or other everybody seems to richest, somehow or other everybody seems to feel they’re being affected by it so, unless the feel they’re being affected by it so, unless the government is prepared to tackle that at a government is prepared to tackle that at a media level, nobody’s going to be unhappy media level, nobody’s going to be unhappy with their decision… not to change taxation.’with their decision… not to change taxation.’

3. The lack of institutional memory within 3. The lack of institutional memory within policypolicy

The Re-cycling of IdeasThe Re-cycling of Ideas

Academic: Academic: ‘What’s really struck me […] is we seem to do the same bits ‘What’s really struck me […] is we seem to do the same bits of work over and over again, you know? A demand will come for of work over and over again, you know? A demand will come for something and because… I don’t keep copies of these things, I think, something and because… I don’t keep copies of these things, I think, ‘oh, I think we’ve done that before!’ And then somebody else will dig ‘oh, I think we’ve done that before!’ And then somebody else will dig out… So on Monday, we’re doing a piece of work which I know we out… So on Monday, we’re doing a piece of work which I know we did two years ago… But… everybody’s changed so nobody knows did two years ago… But… everybody’s changed so nobody knows that that’s what we did two years ago. […] [And] in the DH they’re that that’s what we did two years ago. […] [And] in the DH they’re now subcontracting a lot of their work… So… somebody, some now subcontracting a lot of their work… So… somebody, some agency will be given the job of coming up with something-or-other, agency will be given the job of coming up with something-or-other, and it’s like reinventing the wheel - they’ll have no knowledge of and it’s like reinventing the wheel - they’ll have no knowledge of what the Department, or allied researchers, has already done. […] what the Department, or allied researchers, has already done. […] So I think that fragmentation, which you’ve got with the normal So I think that fragmentation, which you’ve got with the normal process of civil servants moving round is becoming intensified process of civil servants moving round is becoming intensified because of this process of giving the work to outsiders, who don’t because of this process of giving the work to outsiders, who don’t even know what might have happened within the DH.’even know what might have happened within the DH.’

4. Politicisation of the civil service4. Politicisation of the civil service

Aiming to give ministers ‘what they want’Aiming to give ministers ‘what they want’

Civil servant (England): Civil servant (England): ‘If you’ve got a problem, […] the first ‘If you’ve got a problem, […] the first thing you do is to work back in the files and see what you said thing you do is to work back in the files and see what you said last time and then to ask one another what you think we last time and then to ask one another what you think we should do and then to should do and then to make a judgement about what make a judgement about what ministers really want, what’s feasibleministers really want, what’s feasible and what’s politically and what’s politically this, that and the other.’this, that and the other.’ [My emphasis] [My emphasis]

Former civil servant, Lord Bancroft: Former civil servant, Lord Bancroft: ‘seeing that advice which ‘seeing that advice which ministers want to hear falls with a joyous note on their ears, ministers want to hear falls with a joyous note on their ears, and advice which they need to hear falls on their ears with a and advice which they need to hear falls on their ears with a rather dismal note, [civil servants] will tend to… make their rather dismal note, [civil servants] will tend to… make their advice what ministers want to hear rather than what they advice what ministers want to hear rather than what they need to hear,’need to hear,’ (quoted in Hennessey 1995, p130). (quoted in Hennessey 1995, p130).

5. Understanding the decisions health 5. Understanding the decisions health inequalities researchers makeinequalities researchers make

The importance of research funders:The importance of research funders:

Senior academic researcher: Senior academic researcher: ‘[A]cademics are entrepreneurial, ‘[A]cademics are entrepreneurial, they go where the money is and so […] if somebody says, they go where the money is and so […] if somebody says, ‘research project on X,’ you know, ‘cycling,’ we’d all start ‘research project on X,’ you know, ‘cycling,’ we’d all start doing sociology of cycling or something, I don’t know doing sociology of cycling or something, I don’t know [laughs].’[laughs].’

Senior academic: Senior academic: ‘[X - name of civil servant who is a personal ‘[X - name of civil servant who is a personal friend of interviewee], is still amazed that I don’t know things friend of interviewee], is still amazed that I don’t know things like [policy] initiatives that are going on but then, can like [policy] initiatives that are going on but then, can understand when I say, you know academics - we go on a understand when I say, you know academics - we go on a need to know basis. […]. If there’s a call for research and need to know basis. […]. If there’s a call for research and there’s some funding, well, we’re learn about that, you know - there’s some funding, well, we’re learn about that, you know - in twenty-four hours we’ll know about that!’in twenty-four hours we’ll know about that!’

Intentional influences on research by funders?:Intentional influences on research by funders?:

Senior academic: Senior academic: ‘I think one of the difficulties is often ‘I think one of the difficulties is often when there are bids for research funding, it’s almost when there are bids for research funding, it’s almost if the findings or, you know, the messages that are if the findings or, you know, the messages that are required are stated from the start almost. […] When required are stated from the start almost. […] When one looks at research bids, it’s, there are strong one looks at research bids, it’s, there are strong steers in terms of what they’re looking for, what steers in terms of what they’re looking for, what kinds of conclusions one’s being steered towards, kinds of conclusions one’s being steered towards, what kinds of policy messages they want…’what kinds of policy messages they want…’

Intentional influences on research by funders:Intentional influences on research by funders:

Senior policymaker (Scotland): Senior policymaker (Scotland): ‘[T]here is a kind of tension in ‘[T]here is a kind of tension in discussions which go on nowadays between… researchers, who discussions which go on nowadays between… researchers, who basically say, ‘basically say, ‘give us the moneygive us the money - I’ve got a great programme of - I’ve got a great programme of research here… I can’t tell you too much about it, ‘cause the ideas research here… I can’t tell you too much about it, ‘cause the ideas are just beginning to… So, give me the money - you can trust me are just beginning to… So, give me the money - you can trust me and… I’ll produce something. Don’t know what it is but, but and… I’ll produce something. Don’t know what it is but, but something will happen.’ And on the other hand, people like me and something will happen.’ And on the other hand, people like me and […] my colleagues in the MRC, who say, ‘what did we buy for the […] my colleagues in the MRC, who say, ‘what did we buy for the money?’ And, ‘Well, I know you’re very interested in looking at… money?’ And, ‘Well, I know you’re very interested in looking at… health inequalities but actually, I have a problem here - I am health inequalities but actually, I have a problem here - I am required to make policy in this area… at the moment, I have no hard required to make policy in this area… at the moment, I have no hard facts at all… and I really would like some research done… and… by facts at all… and I really would like some research done… and… by the way, I want it done within the next six months and I’ve got that the way, I want it done within the next six months and I’ve got that amount of money available for it. So, I want you to give me the best amount of money available for it. So, I want you to give me the best answer you can within six months, given that amount of money.’ answer you can within six months, given that amount of money.’ And that’s, And that’s, that’s the real worldthat’s the real world.’ .’

The Need to Remain OptimisticThe Need to Remain Optimistic

Most researchers I interviewed wanted to Most researchers I interviewed wanted to make a difference so many described make a difference so many described increasingly focusing on things that they felt increasingly focusing on things that they felt could make a small difference.could make a small difference.

6. How researchers package messages to 6. How researchers package messages to policymakerspolicymakers

Deliberate Ambiguity:Deliberate Ambiguity:Academic: Academic: ‘When I was at [Blank] I could have been much more… critical. ‘When I was at [Blank] I could have been much more… critical.

It isn’t simply that I feel the funding source wouldn’t like me to say those It isn’t simply that I feel the funding source wouldn’t like me to say those things, I actually… would feel it would be a betrayal of the trust that the things, I actually… would feel it would be a betrayal of the trust that the people who gave me the opportunity to spend my time doing that had people who gave me the opportunity to spend my time doing that had in me… and I think, in a way, when I was working at [this organisation] in me… and I think, in a way, when I was working at [this organisation] and they are actually funded through [government department], I and they are actually funded through [government department], I think… they would have looked at me and said, ‘how can you not have think… they would have looked at me and said, ‘how can you not have read what is appropriate to say?’ So I think the censoring is actually self-read what is appropriate to say?’ So I think the censoring is actually self-imposed. […] It isn’t that I think they would come the heavy on me, it’s… imposed. […] It isn’t that I think they would come the heavy on me, it’s… there’s an unwritten understanding that I won’t rock the boat when I’m there’s an unwritten understanding that I won’t rock the boat when I’m writing in that guise. So… at an academic event, I feel I’m me, you know writing in that guise. So… at an academic event, I feel I’m me, you know […] I can be much more pointed in the points I want to make… but… I […] I can be much more pointed in the points I want to make… but… I think when I’m writing through a funding source, which is government… think when I’m writing through a funding source, which is government… and I do out of, and maybe I shouldn’t, I do it out of a sense of loyalty and I do out of, and maybe I shouldn’t, I do it out of a sense of loyalty to… the people who are trusting me not to say things that would make to… the people who are trusting me not to say things that would make them feel uncomfortable… and cast into doubt the judgement that they them feel uncomfortable… and cast into doubt the judgement that they had in saying I was the right person to do the job.’had in saying I was the right person to do the job.’

Fitting in with perceptions of policy preferencesFitting in with perceptions of policy preferences

Academic: Academic: ‘‘If you have poverty and adversity of that nature, If you have poverty and adversity of that nature, nothing’s gonna save you. Now, they [policy makers] are not nothing’s gonna save you. Now, they [policy makers] are not gonna like hear that. [Pause] On the other hand, I have to gonna like hear that. [Pause] On the other hand, I have to say, I think probably some people have enough clout that we say, I think probably some people have enough clout that we don’t need to… be too tactful. But certainly when I was less don’t need to… be too tactful. But certainly when I was less experienced and I was putting in for money on [blanked] and experienced and I was putting in for money on [blanked] and health, we did produce papers which were - how can I put it? health, we did produce papers which were - how can I put it? We weren’t coming out and saying we were absolutely sure We weren’t coming out and saying we were absolutely sure that [blank] causes ill-health and there’s no element of that [blank] causes ill-health and there’s no element of selection. We actually found the perfect way through it, selection. We actually found the perfect way through it, which was to say [removed for anonymity]. Now that, I think which was to say [removed for anonymity]. Now that, I think that’s probably true, actually, but… we were doing it, I was that’s probably true, actually, but… we were doing it, I was doing it, I was pushing people towards it in order to be clever.’doing it, I was pushing people towards it in order to be clever.’

ReferencesReferences

Bevan, G. (2010), Impact of devolution of healthcare in the UK: provider challenge in England and provider capture in Wales, Scotland and Northern Ireland? Journal of Health Services Research and Policy, 15(2): pp.67-68.

Cairney, P. (2009), The role of ideas in policy transfer: the case of UK smoking bans since devolution. Journal of European Public Policy 16: pp.471-88.

Connolly, S., Bevan, G. and Mays, N. (2010), Funding and Performance of Healthcare Systems in the Four Countries of the UK Before and After Devolution. London: The Nuffield Trust.

Greer, S. (2005), The Territorial Bases of Health Policymaking in the UK after Devolution. Regional and Federal Studies 15: pp.501-18.

Mackenbach, J.P. (2010) Has the English strategy to reduce health inequalities failed? Social Science & Medicine, 71:1249–53.

Propper, C., Sutton, M., Whitnall, C. and Windmeijer, F. (2009), Incentives and Targets in Hospital Care: Evidence from a natural experiment. Working paper no. 08/205. London: University of Bristol.

Smith, K.E., D.J. Hunter, T. Blackman, E. Elliott, A. Greene, B.E. Harrington, L. Marks, L. McKee, and G.H. Williams (2009), Divergence or convergence? Health inequalities and policy in a devolved Britain. Critical Social Policy 29: pp.216-242.

Smith, K.E. & Hellowell, M. (2012) Beyond Rhetorical Difference: A cohesive account of post-devolution developments in UK health policy. Social Policy & Administration, 46(2): 178-198.