Linda Marks

Performance Assessment and Wicked Problems: The Case of Health Inequalities:

This article considers the background to one of the projects in the UK Economic and Social Research Councils Public Services Programme: a major; three-year investigation of how health inequalities are being framed for intervention at a local level in post-devolution England, Scotland and Wales. A particular interest is in the difference that performance assessment makes as it engages to a greater or lesser extent with health inequalities.

The Public Health System in England

Introduction Public health and a public health system The evolution of the public health function in England (1) 1974-97 The evolution of the public health function in England (2) 1997-2009 Current issues in the public health system in England Looking to the future.

Wicked Comparisons: Reflections on Cross-national Research about Health Inequalities in the UK

This article discusses a comparative study of how local actors tackle health inequalities in England, Scotland and Wales. The main method used in this study was a thematic analysis of 200 interview transcripts. Its focus was on how health inequalities are framed for intervention by performance assessment systems and the challenge for these systems that their nature as a ‘wicked issue’ presents. The three different national contexts are described, including organizational structures and the use of targets, and the difficulty of making evaluative comparisons is considered. Reflecting on results from the study, it is concluded that both divergence and convergence in themes across the three countries reveal narrative patterns that draw on discourses rather than evidence. The nature of national performance audit regimes appears to play an important part in shaping these discourses, which are themselves evolving, partly in interaction with local feedback.

Health inequalities in England, Scotland and Wales: Stakeholders' accounts and policy compared

OBJECTIVES The election of a Labour government in 1997 brought the issue of health inequalities firmly back on to the policy agenda across the UK. Since then, in the wake of devolution, the need to tackle health inequalities has been highlighted as a policy priority in all three mainland UK countries, albeit with varying degrees of emphasis. This paper reports on a major cross-national study, funded by the Economic and Social Research Council, investigating how National Health Service bodies, local councils and partnerships make sense of their work on health inequalities, and examining the difference made by the contrasting approaches that have been taken to performance assessment in England, Wales and Scotland. STUDY DESIGN Case studies, semi-structured interviews and analysis of key policy statements. METHODS In order to explore how health inequalities have been approached by the three governments (noting that there was a change in governments in Wales and Scotland during this time), key policy statements published between May 1997 and May 2007 were analysed. Concurrently, data from stakeholder interviews carried out in 2006 in case study areas in each country were analysed to determine the extent of alignment between policy and practice at local level. RESULTS This paper suggests that claims about the extent of health policy divergence in post-devolution Britain may have been exaggerated. It finds that, whilst the three countries have taken differing approaches to performance assessment and the setting of targets, policy approaches to health inequalities up until 2007 appear to have been remarkably similar. Furthermore, the first round of interview data suggest that variations in local understandings of, and responses to, health inequalities cannot always be clearly distinguished along national lines. CONCLUSIONS Based on the policy analysis, devolution in the UK does not appear to have resulted in substantively different national policy approaches to health inequalities. Indeed, the overall analysis suggests that (prior to the 2007 elections in Scotland and Wales) the differences between local areas within countries may be of as much interest as those between countries.

Framing health inequalities for local intervention: comparative case studies

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.

Governance for health and wellbeing in the English NHS

Objectives Shifting the focus of health-care systems towards prevention has proved difficult to achieve. Governance structures are complex, incentives may conflict and there are many competing priorities. We explored the influence of governance and incentive arrangements on commissioning for health and well-being in the English National Health Service (NHS) and the governance paradoxes which emerge. Methods Qualitative and quantitative methods were employed. We carried out one national and two regional focus groups; a national online survey of primary care trusts (PCTs); and 99 semi-structured interviews in 10 purposively selected case study sites across England. Interviewees included decision-makers in PCTs, practice-based commissioners, Chairs of Local Involvement Networks (LINks) and of Overview and Scrutiny committees (OSCs) and Voluntary and Community Sector (VCS) members of local health and wellbeing partnerships. Results Case study sites differed in the extent to which they reflected a public health ethos throughout the commissioning cycle, incentivized preventive services through contractual flexibilities or prioritized investment in health and wellbeing. Practice-based commissioners were tangentially involved in the commissioning cycle, public health partnerships or local health needs assessment. While commissioning for health and wellbeing involves working through partnerships, performance management regimes favoured single organizational success. Preventive services were considered at increased risk in times of financial stringency. Conclusions As the NHS in England undergoes further reorganization, it is important to ensure that a systematic, strategic and population-based approach to commissioning is not lost. Governance and incentive arrangements should be critically assessed for their impact on population health and wellbeing.

The training needs of doctors working in English and Welsh prisons: A survey of doctors

In the context of the transfer of the responsibility for prison health from the Prison Service to the National Health Service, a survey of doctors working in prisons reveals doctors’ own high priorities for training in the distinct patient contexts found in prison as well as in certain clinical conditions. The analysis identifies exclusive competences required only for doctors working in prisons and special interest competences that although applicable to practice in the community are particular strengths of doctors working in prisons because of the prevalence of conditions they are required to address.

An evidence base for tackling inequalities in health: Distraction or necessity?

Evidence of effectiveness is prominent as a basis for decision-making. Addressing inequalities is a key UK policy objective to be implemented through national and local strategies. Tensions that emerge in adopting an evidence-based approach for tackling inequalities in health are only partly due to limitations of the evidence base in this area. Three research and development projects on different aspects of addressing the inequalities agenda, carried out in the North East of England between 2000 and 2002, explored how local decision-makers tackled inequalities in health and how this issue was reflected in local strategies. These projects illustrate the breadth of this agenda, different ways in which it can be conceptualized and prioritized at a local level and barriers to its implementation. It is argued that evidence of effective interventions plays a relatively small part in decision-making at a local level. In order to address inequalities in health, greater attention should be directed to ways in which the inequalities agenda is embedded within local monitoring and decision-making processes.

The potential value of priority-setting methods in public health investment decisions: qualitative findings from three English local authorities

Abstract This paper reports on an action-oriented research study providing decision support to three local authorities in England on the prioritisation of public health investment and disinvestment decisions. We adopted a political science perspective, using the multiple streams framework to investigate the use of prioritisation tools in public health spending decisions at a time of severe financial constraints. The challenges and implications of their potential use in everyday practice were explored. Twenty-nine interviews were conducted before the targeted decision support occurred and 19 interviews after the decision support had been delivered. Interviews were held with locally elected politicians, officers and public health professionals based within local government, NHS commissioners and the local independent consumer watchdog for health and social care. Targeted workshops with local stakeholders were facilitated in each site by health economist members of the project team. Structured observational notes were recorded during these workshops and integrated with the interview data. Many respondents expressed an interest in prioritisation tools although some scepticism was expressed about their value and impact on decision-making. This paper analyses the enablers and barriers to adopting priority-setting tools in a local government environment that by definition is political. The findings suggest that the adoption of priority-setting tools in decision-making processes in public health poses some significant challenges within local government and that certain enabling factors have to be present.

Fault‐lines between policy and practice in local partnerships

PURPOSE The purpose of this study is to explore gaps between policy and practice in relation to the involvement of voluntary and community sector (VCS) members in local strategic partnerships (LSPs), using the example of inequalities in health. DESIGN/METHODOLOGY/APPROACH Documentary analysis; semi-structured interviews with VCS representatives from a sample of LSPs in one region of England; semi-structured interviews with key researchers and national stakeholders. FINDINGS National policy imperatives to expand the role of the VCS in decision-making and to make LSPs an important avenue for addressing inequalities in health are not always translated into practice. VCS members are at the sharp end of tensions in LSPs between thematic and neighbourhood approaches, local views and strategic priorities and between democratic and participatory approaches to decision-making. Effective engagement in addressing inequalities in health requires a strategic approach across the LSP which is reflected in the priorities of each of the constituent partnerships. RESEARCH LIMITATIONS/IMPLICATIONS This is a snapshot of LSPs at one point in time and local interviews are restricted to one region of England. PRACTICAL IMPLICATIONS The article illustrates good practice and barriers to VCS involvement in addressing inequalities in health through LSPs. This is relevant to a range of public health partnerships. ORIGINALITY/VALUE The views of VCS members on addressing inequalities in health through LSPs have not previously been researched, despite their key role. Lessons are relevant for multi-agency strategic partnerships with a public health focus in England and internationally.