Use the attached article to answer the questions below separately
1) How does framing health disparities influence the creation of successful interventions?
2) How might the research’s conclusions be used to address health problems besides the case studies it looked at?
3) What are the article’s key case studies, and why were they picked?
4) How do various players, such as decision-makers and community organizations, affect how issues are framed?
Framing health inequalities for local intervention:
comparative case studies
Tim Blackman1
, Barbara Harrington1
, Eva Elliott2
,
Alex Greene3
, David J. Hunter1
, Linda Marks1
, Lorna
McKee3
, and Gareth Williams2
1
Wolfson Research Institute, Durham University
2
School of Social Sciences, Cardiff University
3
Health Services Research Unit, University of Aberdeen
Abstract This article explores how health inequalities are constructed as an object for
policy intervention by considering four framings: politics, audit, evidence and
treatment. A thematic analysis of 197 interviews conducted with local managers
in England, Scotland and Wales is used to explore how these framings emerge
from local narratives. The three different national policy regimes create
contrasting contexts, especially regarding the different degrees of emphasis in
these regimes on audit and performance management. We find that politics
dominates how health inequalities are framed for intervention, affecting their
prioritisation in practice and how audit, evidence and treatment are described as
deployed in local strategies.
Keywords: health inequality, United Kingdom, framing, narratives
Introduction
Towards the end of the 1990s reducing health inequalities rose up the agenda of governments
in several countries, including the UK, reflecting a growing awareness of the existence and
preventability of these inequalities as well as the financial cost of treatment if they were not
addressed (Leon et al. 2001, Mackenbach and Bakker 2002, Wanless 2004). As an example of
Kingdon’s (2003) ‘policy windows’, health inequalities illustrate how a confluence of key
factors can see a problem, previously neglected, enter the policy arena. Kingdon
conceptualises these factors as three streams: a problem stream, where the strength of
evidence brings a problem into or out of focus for policy-makers; a policy stream, which
represents the ability of stakeholders to argue for the plausibility and feasibility of actions to
tackle the problem; and a politics stream, where bargaining between power bases sees
problems get more or less attention and action.
Mackenbach et al. (2002) link the entry of health inequalities into the problem stream to
the better availability of national population and mortality statistics, but evidence of the
problem needed to coincide with effective policy tools and a conducive balance of political
forces for policy change to occur (Cropper et al. 2007, Kingdon 2003, Zahariadis 2008). In
Sociology of Health & Illness Vol. 34 No. 1 2012 ISSN 0141–9889, pp. 49–63
doi: 10.1111/j.1467-9566.2011.01362.x
2011 The Authors. Sociology of Health & Illness 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
the UK the election in 1997 of a Labour government after 18 years of Conservative rule saw
a shift in the politics stream towards taking action on health inequalities, but the new
government also fundamentally changed the policy landscape by devolving power, including
that over health policy, to national governments in Scotland and Wales in 1999. These new
governments, as in England, produced bold statements and strategies addressing health
inequalities (Department of Health 2000, National Assembly for Wales 2000, NHS Scotland
2000). As devolution developed, however, it became increasingly apparent that approaches
differed, especially regarding the use of targets as a means of driving local performance from
the centre (NHS Scotland 2005, NHS Wales 2005, Secretary of State for Health 2005, Smith
et al. 2009).
In England, a fundamental premise of Labour’s public services reform agenda was that
centrally-determined targets were essential to achieve a focus at local level on the
government’s priorities (Barber 2007, Blair 2010). In Scotland and Wales the Labour Party
was also in government from 1999, but in Scotland it was as part of a coalition with the
Liberal Democrats until replaced by a Scottish National Party minority administration in
2007 and in Wales as a majority government until entering a coalition with Plaid Cymru in
2007. There was little enthusiasm in these governments for England’s ‘command and control’
regime: in Scotland because there was more of a culture of trusting professionals to work with
policy agendas that they themselves tended to be more involved in shaping, and in Wales
because of a culture of localism and less prescription from the centre (Greer 2005). These
differences created an opportunity in the UK to compare how the national circumstances of a
problem affect how it is framed, enabling us to investigate the normative character of policy
problems and how this is further constituted by the narrative constructions of those given
responsibility for local implementation (Fischer 2003, Scho¨n and Rein 1994).
Researching this issue invites a sociological perspective, not just as part of the interpretive
turn in policy studies that has sought to understand goals and purposes without any
particular claims about causes, but also because interpretive analysis can offer policy-relevant
insights (Gabe and Calnan 2009, Popay and Williams 2009, Wilkinson 1996, 2005). A
significant aspect of this work is how the problem is constructed and prioritised. Exworthy et
al. (2003) argue that when health inequalities came onto policy agendas in the late 1990s the
policy stream did not couple effectively with the problem and political streams because there
was neither the knowledge nor the commitment needed to overcome the forces driving health
inequality. Exworthy et al. (2002) also argue that while coupling occurred to some extent at a
national level in England – enough for the issue to be on the policy agenda – this was weak
and patchy at a local level. They suggest that the reason for this was that the central
performance management of health inequalities was less than for other imperatives in health
policy, especially reducing waiting times for treatment, which in reality had higher priority
and more visibility in media discussions about failings of the healthcare system.
These authors were writing at an early stage in the implementation of New Labour health
inequalities policy and only considered England. As we see below, policy developed over time
and the nature of performance management was quite different in Scotland and Wales,
offering an opportunity to explore what effects this had on narrative styles and constructions,
and what this reveals about the normative character of health inequality as a policy problem.
Research design: investigating local health inequalities policies
Our study was funded by the UK Economic and Social Research Council’s Public Services
Programme and brought together a team from Durham University, the University of
50 Tim Blackman et al.
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Sociology of Health & Illness 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
Aberdeen and Cardiff University. The project was submitted for and received NHS ethical
approval. We interviewed senior professionals in the NHS, local government and local
partnerships in each of the three countries of Great Britain, exploring how national policy
was reflected in local narratives as well as how these narratives constructed the problem and
responded to it locally. Interviewing was conducted in a regional urban centre and exmining ⁄industrial hinterland areas in each country, selected to achieve some comparability of
geographical context and health status. In each locality, we mapped the organisations
responsible for local policy delivery and the key post-holders whose responsibilities included
health improvement. In England, these organisations were the NHS primary care trusts
(PCTs), the local authorities and local strategic partnerships (LSPs). In Scotland they were
the NHS health boards (HBs), the community health partnerships, the local authorities and
the community planning partnerships. In Wales they were the NHS local health boards
(LHBs), the local authorities and the health, social care and wellbeing partnerships.
We undertook semi-structured face-to-face interviews in two phases during May-August
2006 (n=130) and January-June 2008 (n=67). In total, eleven chief executive interviews,
seven director of public health interviews, 25 performance or finance manager interviews,
and 40 interviews with other senior post holders, such as partnership officers and topic
leads, were conducted in England; in Scotland we carried out twelve chief executive
interviews, four director of public health interviews, 23 performance or finance manager
interviews, and 26 interviews with other senior post holders; and in Wales we undertook
nine chief executive interviews, seven director of public health interviews, 14 performance
or finance manager interviews, and 19 interviews with other senior post holders. The
lower number of interviews in phase 2 mostly reflects a smaller number of organisations
due to restructurings over the intervening period. Few problems were encountered in
accessing these senior staff; we had three refusals in the first phase and six in the second
phase.
The interview schedules were semi-structured and the topics covered how respondents’
organisations defined health inequalities, understood their causes and approached tackling
them; how performance was assessed; whether and how policy or practice had changed
between the two interview phases; how reducing health inequalities compared with other
priorities; whether specific targets were used and their nature; views on partnership working
and its advantages and disadvantages, and examples of partnerships working well and not so
well; the impact of joint appointments across the NHS and local authority; the main drivers
for the organisation’s work on health inequalities; prospects for the future; and the perceived
seriousness of government commitment to narrowing health inequalities compared to other
priorities. Interviews lasted about 90 minutes and were recorded, transcribed, checked and
imported into NVivo for analysis. This used systematic indexing of themes, starting with the
themes in the interview schedules and developing the framework as the analysis proceeded.
This was undertaken by the research assistant (BH) with a sample of transcripts also read by
the lead investigator (TB) and members of the project team. The research assistant prepared
draft thematic analyses, supported by direct quotations. This was an inductive process
involving compiling profiles of organizations built up from the data from respondents,
localities built up from the organizational profiles, and countries built up from the locality
profiles. These revealed patterns of similarity and difference by role, type of organization,
locality and country that were discussed initially by the national teams and then by full
meetings or teleconferences of the whole team and in meetings of the project’s advisory
group. These discussions took the work beyond thematic indexing to an interpretive analysis
that drew on the wider knowledge and expertise of members. In addition, results from the
project were presented to a mixed policy and academic audience at a conference in Durham
Framing health inequalities 51
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Sociology of Health & Illness 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
in March 2009, to which all participating organizations were invited and which further
informed the analysis.
In this paper, we discuss the major themes which emerged from the interpretive analysis:
politics, audit, evidence and treatment. We consider these as ‘framings’, which enable
exploration not only of ‘what’ a policy means but also ‘how’ it means (Yanow 1996). Our
actors were at the ‘meso-level’ of policy implementation where local service delivery is
managed and shaped (Nutley et al. 2007). They are interpretive communities or ‘parties to
the debate’ as Fischer (2003: 143) describes, drawing on Schon and Rein’s (1994) work on
frame-reflexive discourse to ask:
(H)ow is the policy issue being conceptualized or ‘framed’ by the parties to the debate?
How is the issue selected, organized and interpreted to make sense of a complex reality?
The framing of an issue supplies guideposts for analyzing and knowing, arguing and
acting. Through the process, ill-defined, often amorphous situations can be understood
and dealt with … Frames highlight some issues at the same time that they exclude others
(Fischer 2003: 143)
Particularly important is to understand defining claims, such as about priorities or how
success is identified, because these serve to justify specific courses of action. The first framing
we identify is politics; the process of whether and how an issue becomes defined politically as
a problem needing state action. The second is audit, or the scrutiny processes characteristic of
new public management that aims to exercise arm’s length control over local implementation,
based on the use of targets, performance indicators and sanctions (Clarke 2006, Travers
2007). The third is evidence, which is an important type of framing in health policy and
practice, representing a particular type of empirical knowledge produced by a research
process, and mediated by interpretation and prevailing paradigms (Nutley et al. 2007). The
fourth is treatment or the influence of the medical model and pharmaceutical interests in
framing health problems as questions of individual treatment, using health technologies,
rather than having social causes and solutions (Williams 2003). These framings are
summarized in Table 1 and discussed in turn in the following sections.
Framing health inequalities politically
There were political changes in all three countries between the phase 1 and phase 2
interviews. In England, Labor remained in power but the prime minister changed from
Tony Blair to Gordon Brown. Health inequality was generally seen by our respondents to be
a high priority under both leaders but only to have become embedded in mainstream practice
and performance monitoring by phase 2. Rather than a linear process of policy
consolidation, the lack of mainstreaming in 2006 was not because of it being an early stage of
policy development, but because the NHS was preoccupied with a budget crisis while being
under intense government pressure to meet hospital waiting time targets. By 2008, finances
and waiting times were under control, allowing health inequalities to rise up the policy stream
and receive more attention. However, the conditional commitment to the problem, as a
priority that could be eclipsed by other imperatives, was revealed again by respondents
talking about the reorganizations that had taken place since 2006. These were meant to
improve the efficiency of how services were commissioned and delivered, but were
experienced as impeding the partnership working needed to tackle health inequalities by
causing churn in personnel and disrupting relationships. The chair of an LSP commented:
52 Tim Blackman et al.
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Sociology of Health & Illness 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd
Table 1. Alternative framings of health inequalities in selected localities of England, Scotland and Wales, 2006-2008
Political framing Audit framing Evidence framing Treatment framing
England High priority to narrowing the gap
between areas initially eclipsed by
pressure to reduce hospital waiting
times and budget deficits, and
impeded by reorganizations. Health
inequalities increasingly constructed
as a healthcare issue of earlier
diagnosis and treatment.
Health inequalities framed as
national and local targets,
promoting local action and rising
spending, with strengthening focus
on role of NHS services in making
short term gains. Failure to achieve
targets not a high stakes issue.
Evidence-based framings
increasingly dominated by
treatment model of intervention
and weak with regard to social
determinants and lifestyle
interventions which lack causal
modelling.
Imperative for performance
indicators to show progress against
targets biases action to early
detection and medication, where
there are significant spending
increases reported.
Scotland Strengthening priority to improve
health in the most disadvantaged
areas, with shared commitment and
stable relationships across local
government and NHS partnerships
and levels of government, and
strong acknowledgement of social
determinants.
Targets for health improvement are
not strong framings, with emphasis
on local innovation and evaluation
of what works, and acceptance of
long time spans for change to
occur. Failure to achieve targets
not a high stakes issue.
Evidence-based framings
strengthen, mainly as an evaluative
approach to lifestyle interventions,
but expected long-term gains too
intangible to affect spending
significantly,
Treatment model subordinate to
emphasis on living conditions and
lifestyles, but not perceived as
reflected in significant spending
increases because of the difficulty
of making a financial case.
Wales Weakening priority after social
determinants discourse is eclipsed
by media-fueled preoccupation
with acute services and waiting
times and politically damaging
comparisons with England. Health
inequalities increasingly constructed
as issues of lifestyle as well as
access to care.
Local delivery of standards with no
connection to national targets or
national performance assessment.
Health inequalities not universally
an operational or spending priority
locally beyond access issues. Health
agenda more driven by waiting
time targets.
Evidence available from
evaluations but overshadowed by
hospitals and their spending needs.
Health problems framed as a
legacy of past heavy industry.
No systematic addressing of health
inequalities locally. Preoccupation
in deprived areas is with access to
treatment.
Framing health inequalities 53
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Structural change and reorganization has consistently got in the way of actually focusing
on issues that we need to deal with in the city. My big frustration is that I’ve sat in meeting
after meeting after meeting where people have been talking about who’s round the table,
who is involved, who’s not involved and I keep saying, ‘I don’t care. I want us to get on
and do things’. Every six months we have another discussion about who sits round the
table.
The instability caused by reorganizations under England’s command and control regime
contrasted with Scotland where the NHS was described as relatively stable. The Scottish
National Party narrowly assumed power in 2007 and this was said by some to bring a
strengthened resolve to priorities public health and tackle health inequalities. Local
partnerships were widely regarded as working well and relationships between individuals
across organizations were often long-standing, with informal contacts described as common.
There was also a strong theme of a public service value and a shared commitment to working
together across local government and the NHS.
In contrast to England and Scotland, respondents in Wales did not see any strengthening
of the health inequality agenda at the national level over the period. Following the new
coalition government of Labor and Plaid Cymric coming to power in June 2007, some felt
that the issue had become even more eclipsed than under a Labor majority administration
in 2006, when most of our respondents saw the priority of the Welsh government to be
waiting times and financial balance in the NHS. There were comments that the new health
minister was preoccupied with acute services, centralizing control and populist measures that
focused on care services and treatment. This example is from a director of public health:
It’s pretty clear to me that over time the priorities have shifted evermore towards waiting
times and financial balance. If anything, I’d have to say that’s probably happening more
now as the financial uplifts for the NHS begin to die away and, especially, if we end up in
economic crisis. So, the warm words are still there but it’s difficult to link that through to a
coherent attempt at solving health inequality.
There was a view that, despite broad encouragement of a wider wellbeing and equality
agenda through locally developed Health, Social Care and Wellbeing Strategies the Welsh
government was not focusing on health inequalities. In general, it was felt that the priority
given by the government to waiting times, against which there were targets and local
sanctions, was constraining the availability of NHS funding to develop new services that
could target inequalities and skewed local priorities towards those that were considered to
have disciplinary consequences for senior managers.
We can consider these local narratives against the policy background in each country.
Devolution created conditions for different party politics and distinct policy debates and
actions (Greer 2005, 2009). In England, at the time of our interviews over the period 2006 to
2008, there was a commitment to ‘narrowing the gap’ by reducing ‘differences in health
between those at the top and bottom ends of the social scale’, with performance assessment
against targets and an emphasis on encouraging and enabling people to ‘make healthier
choices’ (Secretary of State for Health 2005: 10-11). In Scotland, the focus was on increasing
the rate of health improvement in the most deprived areas, and emphasizing wider
determinants rather than individual behavior change: ‘addressing aspects of poverty such as
improving people’s employability, increasing young people’s confidence and skills and
regenerating the most disadvantaged neighborhoods’, also on the basis of setting targets to
increase the rate of health improvement (NHS Scotland 2005: 22). In Wales, in a gradual
54 Tim Blackman et al.
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shift from an early social determinants approach, references to tackling health inequality in
policy documents were more tentative because, for reasons discussed below, the politics
stream had become preoccupied with improving access to healthcare rather than prioritizing
public health. Moreover, discussions about health improvement were increasingly framed in
terms of behavior change, marked by the launch of Health Challenge Wales in 2004. So,
although there was an aim to ‘improve health and reduce, and where possible eliminate,
inequalities in health’, there was an overriding emphasis in policy documents on modernizing
services and improving access to care, while also addressing behavior related to smoking,
diet and alcohol (NHS Wales 2005: 4).
To understand the politics of how health inequalities were constructed for policy
intervention, we need to consider aspects of each policy regime. In England, Labor adopted
area-based initiatives as an approach to ‘joining up’ action across a number of policy fields
(Clark 2002, Smith 1999). In the case of health policy this represented an explicit
commitment to narrowing inequality; from 2001, PCTs that included within their
geographical boundaries local authority areas scoring in the bottom 20 per cent nationally on
an index of deprivation and poor health – known as ‘Spearhead areas’ – were required to
demonstrate how they were narrowing their gaps in life expectancy. The national target was a
10 per cent narrowing by 2010 between the Spearhead areas and the national average (which,
according to the National Audit Office (2010), will not be achieved). Scotland also used an
area-based approach, but to identify small areas where the government wanted to see faster
improvement in health outcomes rather than to measure the gap between these areas and the
national average. One of the challenges of the English approach was that national average
health outcomes are likely to increase faster than those for the most deprived areas, making
the English strategy a demanding game of catch-up. The Scottish approach avoided this, but
appears to have been framed not as an easier option but because there was no acceptable
reference point. A senior civil servant explained to us that the Scottish government did not
want to have an objective of narrowing the gap between the most deprived areas and the
Scottish average because the averages for key measures such as life expectancy were among
the lowest in Europe, so not something to aspire towards. The alternative of measuring the
gap with the UK or England was not politically acceptable to a Scottish government. A
monitoring report published in 2006 noted that progress was on target for all the health
inequality targets, which were due to be met in 2008 but were not further reported on
(Scottish Government 2008).
Wales presents a scenario where we see the overlapping influences of different framings.
Comparison was also important for the Welsh government: not, as was the case in Scotland,
rejecting comparison with England, but instead finding itself ineluctably and unfavorably
compared with England, and to some extent Scotland, in the media. These comparisons were
about waiting times for treatment, the rise in which, compared with England’s reductions,
forced the government to move away from the public health emphasis of its health minister
Jane Hutt and priorities improving access generally to healthcare, with the controversy
accompanying the waiting time figures leading to Hutt resigning. However, this shift at
national level was paralleled by a persistent belief in the strength and value of local
governance and action, particularly regarding areas requiring cross-sectoral solutions. From
2003, Health, Social Care and Wellbeing Strategies were the joint legal responsibility of local
health boards and their coterminous local authorities for the planning of health services and
relevant local authority activities. The first guidance on these strategies stressed local
leadership, responsibility, co-ordination and analysis (Welsh Assembly Government 2003).
Whilst there were national targets for healthcare organizations to reduce waiting times,
efforts to address health inequalities were felt to be a matter for local performance
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management and self-assessment. This is also reflected in the approach in Wales to local
authority performance which focuses on local autonomy and self-assessment (Downe et al.
2010). At the time of our study, there were no national targets for tackling health inequalities
that were required to be adopted by local NHS organizations in Wales or local authorities.
Audit framings of health inequality
In the English localities, respondents in the PCTs generally welcomed how national targets
had acted to priorities work on health inequalities, even though these targets were often said
not to be real ‘bottom line’ priorities equivalent to balancing budgets, waiting times and
patient safety. Some still saw health inequality as a ‘Cinderella’ area where demonstrating
value for money was harder than for competing claims on spending from acute services,
although certainly more positive comments were made in 2008 than in 2006 about the
amount of spending on tackling health inequality. PCT respondents said they were
prioritizing the issue in how they commissioned services. A PCT director of performance
development said:
We’re putting our money where our mouth is more than we were. Our annual operational
plan is a very direct alignment of the rhetoric with the actual practicalities of deploying
resources and the outcomes of course do reflect some of the longer-term NHS plan targets
… There’s a whole range of things clustered now under there so the targets in that sense are
far more aligned to the longer-term preventative regime than they’ve ever been.
There was also some re-thinking of how healthcare services needed to change. We were told
that the NHS could work against narrowing health inequalities because of the ‘inverse care
law’: those with the greatest ill health have least access to the services they need (Tudor Hart
1971). Health inequalities, therefore, needed a dedicated proactive approach, as explained by
this director of public health:
We realized a couple of years ago that actually we were potentially increasing health
inequality. So we’re now focusing on our harder-to-reach groups … They’ve got more
baggage and problems and difficulties, so in a way the more we target and try and reduce
inequity the harder the job gets … But that’s good, it’s just hard.
In Scotland there was less talk about targets than in England, although waiting times figured
prominently when targets were discussed. The targets for health improvement were generally
regarded as useful, but there was little of the narrative in England of actions driven by
targets, and a view that performance-managing health inequalities too closely could inhibit
the trial and error approach needed to learn how to tackle complex issues. An HB director of
public health commented:
There’s more of a national understanding now that we need to start adopting this
continuous improvement philosophy rather than just simply stamping you’ve not done this
and you’ve not done that, you’ve not hit this trajectory … Even if you can’t say this will
lead to a two per cent reduction in health inequalities, even though you can’t prove that,
you can legitimately say ‘yes but it will impact because we’ve used the best evidence that we
have available to show that this is the correct continuous improvement route’.
56 Tim Blackman et al.
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Scottish respondents were more likely than in England to talk of the complexity of health
inequality, in which healthcare interventions had limited relevance and short-term targets
little applicability. This caused some frustration that the case for more spending was hard to
make. There was a view among Scottish respondents that health inequalities were not really
influencing how NHS budgets were deployed because of the difficulty of making a causeeffect connection. The speculative and long-term nature of any pay-back on spending was
described by this health board performance manager as a problem when it came to shifting
resources:
The difficulty is that the time span is going to be quite a number of years, maybe even half
a generation, and you need the resources to invest in that end, but you’re not going to see
any savings for maybe 20 years. So it’s not about, you know, we’ll stop treating people for
heart attacks and instead we’ll stop them smoking.
In Wales, there was little evidence of health inequalities being an operational or spending
priority; health inequalities were said not to figure in any performance assessment
frameworks and the health agenda was regarded as driven by waiting times. The
performance management system for the NHS in Wales was described as making policy by
default because meeting waiting time targets was rewarded financially and sanctions were
imposed for poor performance, so other concerns were inevitably a lower priority. A health
board director of finance observed:
I’m not saying that we’re told not to deliver on health inequalities but you’ve got to
achieve the service targets and they’re the ones you’ll be criticized on … the number one
priorities such as waiting times for accident and emergency, cancer and cardiac … If you
fail to achieve the targets essentially they are imposed on you.
There were few references in the Welsh interviews to gauging the scale of local health
improvement that was needed and to targeting interventions, but a lot to coping with
demand on services. Some NHS respondents did regard health inequalities as a top priority
but the variability in these views reflected the lack of a strong national steer. Local authority
respondents talked of the issue as important and addressed by work on regeneration, skills
and housing, including targeted social programmers, but there was little evidence of specific
plans to address health inequalities driving resource decisions. This comment by a board
partnership manager captured a general theme in many interviews:
The health and wellbeing strategy is really all about tackling health inequalities. But a lot
in there hasn’t actually required putting resources into it … you know, putting your money
where your mouth is.
We can see the different national audit cultures reflected in these narratives but not quite as
might be expected. In England, the ‘command and control’ audit culture associated with
New Labour public sector reforms has been dubbed a regime of ‘targets and terror’ (Bevan
and Hood 2006: 421). This is because of the use of managerial sanctions for underperformance, which has much less prominence in Scotland and Wales where there has been
more emphasis on co-operation and collaboration between levels of government. However,
we see little ‘terror’ about the health inequality targets in local narratives and they were often
welcomed as signifying that health inequality was high in the problem stream because
Framing health inequalities 57
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progress was audited, even if the reality of the political stream was that these targets did not
represent high stakes for senior management.
Scotland adopted health inequality targets in 2004, not only later than England but in the
context of Scotland’s different performance regime. The targets were aimed at health
improvements in the most deprived fifth of small area data zones, focusing generally on
reductions of around 10 per cent between 2003 and 2008 in cancer and CHD mortality and
smoking prevalence. Scotland’s local health boards were required to report annually to the
Scottish government on what they were doing to meet an agreed trajectory for each board to
meet these targets. Face-to-face meetings involving government ministers and emphasizing
self-assessment reflected a partnership approach between politicians and professionals.
Wales also adopted national health inequality targets in 2004. These, however, were not
quantified and aimed at a more rapid but unspecified reduction in mortality from coronary
heart disease and cancer among the most deprived groups compared to the national average.
In addition, in 2006 a series of national child poverty targets were published that included
several measurable health inequality targets. None of these were performance indicators for
local NHS or partnership organizations against which they were required to account for their
performance. This is not to say that there was no requirement to address health inequalities
or no assessment of progress. The Healthcare Standards for Wales outlines in standard 29
the requirement of healthcare organizations to address health inequalities through Health,
Social Care and Wellbeing Strategies (Welsh Assembly Government 2005: 14). A balanced
score card was introduced to support self-assessment of performance against internally
agreed plans and targets to meet the standards but, as interviewees emphasized, these were
local targets with no reference to how they connected with national health inequality targets.
Alongside little reporting of comparative data this reflected the localist paradigm in which
devolution in Wales was implemented, within which local government had more influence
and autonomy than its English and Scottish counterparts, including less intensive
performance assessment from the center (Blackman et al. 2006, Downe 2010).
Evidence framings of health inequality
Respondents often said that decision making was evidence based, but published research was
rarely referred to, and evidence generally meant good practice gleaned from conferences or
official guidance. Very few respondents pointed to evidence that their programmers to tackle
health inequalities were having a measurable effect. Why local trends were going in the
direction that they were could rarely be explained. Epidemiological evidence was said to be
influential in the English localities in supporting investment in early detection and treatment,
but in Wales, evidence from evaluations of government-funded area-based health initiatives
was said to be overshadowed by the powerful position of hospitals and their spending needs.
In Scotland we found a trend in respondents’ accounts between 2006 and 2008 towards
increasingly focused and evidence-informed initiatives, mainly to support healthier lifestyles,
and often with evaluation built into the design of the intervention. There was in all countries
a surprising lack of scepticism about lifestyle interventions, given how limited the evidence is
that these interventions can be effective among low income groups, and the time and effort
they generally need compared to their mostly modest results (Jain 2006, Michie et al. 2008).
Health indicators were commonly regarded as demonstrating how much needed to be done
rather than a means of assessing whether the right things were being done.
In Wales, local authority respondents often said that existing services by their nature were
narrowing health inequalities over time because local public services were mainly supporting
58 Tim Blackman et al.
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poorer people. This head of performance management in one of the local authorities
commented that if framed as a strategy to address health inequality his services would be
meeting this objective:
So if you looked and if you set out all these different services, yes you could put it under an
all-embracing health inequality programe … I’m sure they all make a contribution but
there’s no overarching policy.
This view was felt by public health respondents in Wales to result in a non-committal,
unfocused and ultimately disengaged approach to what should have been a joint effort to
address health inequalities. Area-based health interventions funded by the Welsh
government, such as the Sustainable Health Action Research Programme and the
Inequalities in Heath Fund, had evaluation built into the programmes. Public health
professionals, however, locally struggled to find ways of using evidence so that resources
would be levered from either NHS or local authority funds. At the time of our study local
public health directors were employed by the National Public Health Service and not the
local health boards, where they served as non-executive board members in a role they often
saw as structurally weak in informing local strategic and commissioning priorities.
These accounts contrast strikingly with the extent to which evidence-based practice is often
claimed to have become a paradigm for the British NHS. For health inequalities, both the
problem and policy streams have been compromised by how difficult it is to establish
generalizable knowledge that demonstrates ‘what works’, making it harder to move the issue
up the political stream, especially when short-term progress over electoral cycles is so difficult
to demonstrate. The aspiration among many public health practitioners and researchers is
still that tackling health inequalities can be evidence based, whether by using schematic ‘logic
models’ that aim to predict and then evaluate multiple contributions to health outcomes, or
by integrating a wide range of quantitative and qualitative evidence to assess the distribution
of effects (Petticrew et al. 2009). However, as we see in the next section, the need for evidence
that policy commitments are getting results can bias action towards what is likely to have
short-term effects. This was most evident in the English localities, where there was an
imperative for performance indicators to show progress.
Treatment framings of health inequality
Rychetnik et al. (2002: 125) point to the way that an evidence hierarchy which privileges
randomized controlled trials may attenuate options for improving health, biasing what is
regarded as evidence-based practice to:
… interventions with a medical rather than a social focus, those that target individuals
rather than communities or populations, and those that focus on the influence of the
proximal rather than distal determinants of health
The treatment model is often regarded as reflecting the dominance of hospital consultants
and technological medicine, but it also reflects popular attitudes about health. We saw this
demonstrated by the way that the Welsh government had to prioritize treatment in the face of
media comparisons with English waiting times, eclipsing the earlier commitment to public
health. However, we also found that in England the health inequality targets were focusing
action on medical interventions. This was a clear trend in the interviews between 2006 and
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2008, with the importance of finding people in the community at risk from deadly diseases
and getting them into treatment heightened by the imminence of the 2010 targets. This upscaling of interventions based on early detection and secondary prevention using drugs, such
as statins, antihypertensives and smoking cessation aids, was policy driven, and strongly
influenced by the national audit regime and associated guidance and tools (Bentley 2008).
This increasing focus on treatment was not so apparent in Scotland, where projects to
improve local economic and social conditions and promote healthier lifestyles featured more
in respondents’ accounts. It is likely that the absence of strong pressure from targets was an
important factor in this respect, but Scottish respondents were more likely than their English
counterparts to bemoan a lack of influence on spending to tackle health inequalities. This
appeared to be linked to the medical case that actors in England could make for spending on
measures to reach people currently not presenting with conditions that could be managed
with prescribed treatments, given the strong policy endorsement of this paradigm and its
expected short-term effects on mortality. Making a budgetary case for preventative health
improvement measures was much more difficult because of the longer and more speculative
pay back.
In Wales, with an absence of national targets translated into local performance assessment,
no strong national policy steer was perceived locally, and health inequalities were not
addressed systematically in local planning or budgeting. Between 2006 and 2008, policy in
Wales was seen as either not having moved on or having shifted away from tackling health
inequalities because of the government’s preoccupation with hospitals. This was partly seen
as political opportunism, given the prominence of hospitals in the minds of the public and
media, and partly as a reality, given the burden of poor health left by the legacy of past heavy
industry. In this context, Welsh policy was said to have an emphasis on equity that skewed
attention to access issues. Health inequality – inequalities in outcomes rather than access to
care – had little specific focus.
Conclusion
In policy analysis, framing reflects a balance of influences, political and managerial, on
understandings of ends and means (Daviter 2007, Greer 2005). Thus, it is often argued that
England’s widespread use of performance indicators frames action to implement policy in
ways that mean ‘what’s measured is what matters’ (Bevan and Hood 2006: 517). It has also
been argued that by constructing issues narrowly, performance indicators engender less
effective practices and, combined with an oppressive emphasis on compliance and sanctions,
encourage gaming (Seddon 2008, Tilbury 2007). In England, the coalition government
formed between the Conservative and Liberal Democrat parties following the May 2010
general election has been forthright in blaming Labor’s ‘top-down’ targets for creating a
mentality in the NHS and local government that puts process before outcomes (Secretary of
State for Health 2010).
Interviews in the English localities revealed a more complex picture. Shifting framings of
targets was significant despite ‘policy’ not changing: political pressure focused the minds of
local actors in ways that neither audit nor evidence could do on their own. In 2006, what
mattered in England were ministerial exhortations and directives to meet the targets for
waiting times and financial balance. By 2008 these issues were under control and the health
inequality targets came more within the frame, although not immune from managerialist
efforts to improve the efficiency and effectiveness of healthcare delivery. Boosting primary
care came to be seen as the way to make short-term progress with meeting the 2010 targets
60 Tim Blackman et al.
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and this took priority over any evidence-based arguments about the need to direct more
resources upstream to tackle health inequalities preventatively, especially as such evidence
lacked information about cost-effectiveness (Wanless 2004).
Respondents in Scotland worked under a less strong target regime and often echoed
some of the criticisms made of targets in the literature, especially their applicability to
complex problems (Hunter and Marks 2005, McCormick and Fulop 2002, Seddon 2008).
However, while both the Scottish and Welsh interviews often revealed an evaluative
culture locally that recognized the complexity of health inequalities, this generally appeared
not to be influencing the allocation of NHS resources, while local government services
were often assumed to be contributing to narrowing health inequalities rather than this
being demonstrated.
The power of the political stream is clear from our analysis. In England it ran though how
audit was perceived in practice and shaped the policy stream that in phase 1 was more
attentive to waiting times and budgets than health inequality, and in phase 2 delivered the
medicalisation of health inequalities as a way of meeting short-term targets. In Wales the
political stream moved away from tackling health inequality under pressure from a media-led
framing of the country’s health problems as a failure to match England’s waiting times and
deliver equity of access to healthcare. In Scotland, tackling health inequality was seen by
respondents as the object of joined-up working to tackle the issue facilitated by a political
stream that engendered stability and partnership working, but Scottish public health
directors still bemoaned their inability to bend NHS spending. Only in England were there
clear accounts of such bending because this was target driven. In none of our localities in any
of the countries did we find a clear link in actors’ accounts between what was being done and
the evidence for doing it, beyond broad generalizations. There was also as yet little systematic
learning from the interventions that were being pursued, a finding echoed in a UK
Parliament committee investigation of health inequalities (House of Commons Health
Committee 2009).
While evidence of the problem may be deployed in these narratives, scientific forms of
knowledge such as epidemiology cannot be used as any kind of trump card because policy
and political streams reflect other factors such as the availability of tools and levers to deliver
change, media pressure, hospital power, stances towards working with targets, working in
partnership and working with evidence, and timescales driven by electoral cycles. In
developing a sociological approach to health inequality as a field of investigation and action,
this kind of understanding is necessary to move us beyond rather naive linear ideas about the
relationship between the ‘best evidence’ and strategies for what is to be done.
Address for correspondence: Tim Blackman, Wolfson Research Institute, Durham
University, Queen’s Campus, University Boulevard, Thornaby, Stockton-On-Tees, TS17 6BH
e-mail: [email protected]
Acknowledgements
This article is based on a project funded by the UK Economic and Social Research Council under the
Public Services Program (Ref RES-153-25-0079). We would like to thank for their contributions our
interviewees, two anonymous referees and the project’s advisory group: Derek Warless, Kay Barton,
Martin Gibbs, Tony Elson and Beverley Frowen. Responsibility for the interpretations and conclusions
made in the article lies entirely with the authors.
Framing health inequalities 61
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