Wicked issues and performance assessment: The case of health inequalities

A comparative study of England, Scotland and Wales 2007-09

• Prof Tim Blackman • Prof David Hunter• Linda Marks• Barbara Harrington

• Prof Lorna McKee• Dr Alex Greene • Prof Gareth Williams• Dr Eva Elliott

Female life expectancy, Wales

75

76

77

78

79

80

81

82

1996-98

1997-99

1998-00

1999-01

2000-02

2001-03

2002-04

2003-05

2004-06

Wales

Regional centre

Hinterland 1

Hinterland 2

Teenage conception rate: England, Wales and Scotland, 1998 to 2005

30

35

40

45

50

55

60

1998 1999 2000 2001 2002 2003 2004 2005

Source: Office for National Statistics

rate

per

100

0 w

om

en a

ged

15-

17

England

Scotland

Wales

Do targets matter?

• ‘The targets have driven change. Would this have happened without them? The answer is perhaps … but not as quickly or effectively’ (PCT performance manager, England)

• ‘You’re not going to see any savings for maybe twenty years … So it’s not about we’ll stop treating people for heart attacks and instead we’ll stop them smoking’ (Health Board performance manager, Scotland)

• ‘League tables are a bit unhealthy … every area has particular issues and problems’ (Health Board Director, Wales).

Joint outcome agreements• Scotland

– (New) Single Outcome Agreements

– Community Planning Partnerships

– A development of partnership working

• England– Local Area Agreements– Local Strategic

Partnerships– A development of

performance assessment

• Wales– (New) Local Delivery Agreements, linked to Health,

Social Care and Well-being Strategies– Local Service Boards– Ministerial oversight– Sharper focus in second round HSCWB strategies on

‘baselines and objectives’

Reorganisation

• Wales– Planned and ongoing reorganisations to

health boards and public health services

• England– Larger PCTs or joint management

arrangements– Some local government reorganisation into

larger councils

Partnerships

• ‘Working well’ in Scottish localities– Some long-standing relationships– ‘Working together’ a value, different to England

• Mixed views in the English localities– A forum– Variable real engagement– Health inequality targets mainstreamed in PCTs but

not in local councils• Mixed views in the Welsh localities (mostly

negative)– More about collaboration between health and social

care services than health improvement– Building trust still an issue– Funding regarded as an impediment

Success?

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

Challenges• Being methodical:

– ‘It’s much more amenable to something like sickness absence or waiting times, where it’s very good. Where it’s much more difficult, but I think still applicable, and the discipline or it is very good, it’s much more difficult when you’re starting to look at behaviour change and health improvement, which is long term, it’s multifactorial’ (Scotland)

• Making the case– ‘We keep reminding people that health inequalities are

widening but it’s not helpful in that it hasn’t actually made a difference to the outcomes for the individuals that we need to be concerned about’ (Scotland)

• In Wales performance management was skewing attention away from health improvement and health inequalities– ‘I’m not saying that we’re told not to deliver on health

inequalities but you’ve got to achieve the service targets … the number one priorities such as waiting times for accident and emergency, cancer and cardiac‘.

Constructing ‘health inequalities’

• Health inequalities were widely seen in all countries as caused by deprivation– but to manifest as ‘cultural’ issues about deep-seated

unhealthy behaviours and low aspiration

• Commissioning in the English localities was said to be resourcing large-scale screening and awareness-raising programmes– said to be evidence-based but driven by performance

assessment and availability of models for secondary prevention.

• Commissioning in Wales– No driver from Health, Social Care and Well-being

Strategies

• Local councils regarded their mainstream services as intrinsically likely to reduce health inequalities– Specific exceptions were mainly measures to reduce

smoking, alcohol consumption and fuel poverty, and generally targeting deprived areas.

– No modelling

• ‘The local authority has levers, relevant to lots of little determinants … some of these are not priorities for the local authority so although they’re in their gift the local authority tends to see itself as a series of delivery empires’ (Wales)

Intervention – at what level?

• Life expectancy targets not something than can be performance managed

• More talk about performance managing interventions in the key causes of life expectancy gaps– ‘We realised a couple of years ago that

actually we were potentially increasing health inequality’ (DPH, England)

• More causal chain thinking starting to develop– ‘So we need to be clear about assumptions and we

are going to judge whether that in fact has been a factor or whether it’s other factors …’ (Scotland)

– Now we’re focusing on our harder to reach groups … the whole task of behaviour change is harder because they’ve got more baggage and problems. It’s OK but it’s hard.’ (England)

• Wales tended to be an exception– More of a view that health inequalities could only

really be addressed with long-term economic and fiscal measures, with the NHS meanwhile managing the post-industrial legacy of chronic ill-health.

Break-out groups

• Health inequality targets– Driving change?– Too short-term?– Invite unhelpful comparisons?

• Joint outcome agreements and strategies– Just different targets?– Joining up actions effectively?

• Partnerships– Working well?– Delivering?

• Reorganisations– Helpful or damaging?

• For all questions:

• What can be learned from national comparisons?

• Has our research missed any key issues?