Martin Higgins

Health inequalities: the need to move beyond bad behaviours

Health inequalities have been observed internationally across a number of dimensions (including, eg, socioeconomic position, ethnicity and gender) and have persisted over time.1 The lack of progress in addressing them has disappointed many within public health, particularly given an apparent prioritisation of health inequalities in UK policy.2 Building on recent research highlighting the limitations of addressing health inequalities by trying to change health behaviours of individuals,3 we argue that attempts to tackle health inequalities are impeded by the current framing that dominates much public health policy and research. We suggest some alternative ways forward. Policy analysts have drawn attention to a recurrent policy emphasis on health behaviours in the UK, despite acknowledgment among decision makers that wider social and economic factors are important.4 This approach has been reinforced by researchers focusing on addressing health inequalities by modifying health behaviours via individual-level interventions, which do not fully take into account the impact of the social and economic environments in which people live over time.5 This preoccupation is illustrated by a recent Kings Fund study that reported increasing inequality in what the authors call the ‘clustering of unhealthy behaviours over time’ in England.6 Even when governments commit to addressing social determinants of health, specific actions and interventions often revert to trying to modify individuals’ behaviours. Hilary Graham describes this process as follows: A recurrent slippage occurs as the policy statements move from overarching principles to strategic objectives, with a broad concept of determinants giving way to a narrower focus on individual risk factors.7 While there is clearly a role for addressing health behaviours as part of efforts to reduce health inequalities, this ‘lifestyle drift’ neglects …

How evidence based is English public health policy

Srinivasa Vittal Katikireddi and colleagues’ analysis of the government’s white paper Healthy Lives, Healthy People finds many of the interventions proposed lack evidence of effectiveness and some have even been shown not to work

UK Public Accounts Committee report on health inequalities.

206 www.thelancet.com Vol 377 January 15, 2011 Authors’ reply We appreciate the comments from Tetsuya Tanimoto and colleagues, and Ian Haines and colleagues. They allow us to clarify a few important points. Tanimoto and colleagues note that second-line therapies might aff ect overall survival. We agree with this statement. However, as of June, 2009 (closure of database for analysis), only a minority of patients had received second-line therapy. Therefore, the results were too preliminary to allow reliable conclusions. Moreover, a high proportion of patients with a short progression-free survival had a del(17p) mutation, which predicted a short progression-free survival and overall survival in this trial. Therefore, 3 years after randomisation, genomic aberrations seemed to have a stronger eff ect on outcome than the type of second-line treatment. 70 patients were assessed as having stable disease after three courses (30 in the fl udarabine, cyclophosphamide, and rituximab [FCR] group and 40 in the fl udarabine and cyclo phosphamide [FC] group); most of them continued with study treatment. So far, more patients in the FC group have received second-line therapies than in the FCR group. A systematic assessment of the response to these therapies would be premature and based on a very small subset of patients. We do not agree with Haines and colleagues’ comments on the study population. The proportion of Binet A patients is very small at only 5%; 31% of patients were Binet C stage. The role of granulocyte colonystimulating factor (G-CSF) needs to be further investigated. However, results from prospective phase 3 trials have found that fi rst-line treatment for chronic lymphocytic leukaemia (CLL) with FC or fl udarabine alone can be applied without the addition of G-CSF or similar growth factors. In this trial, G-CSF was given only in about 2% of courses, again suggesting that FCR or FC could be safely given in fi rst-line therapy of patients with CLL. The German CLL Study Group is making every possible attempt to follow up patients from its trials until death to gain insight into the longterm consequences of all treatment modalities. Therefore, this study was not discontinued. Although the results of the fi rst interim analysis were robust, reliable, and signifi cant, we decided to repeat the analysis with 1 additional year of follow-up and a longer median obser va tion time (37·7 months). These results were reported in the published manu script. The primary endpoint of this trial was progression-free survival; secondary endpoints were response rates and overall survival. The repeated analysis with a median observation time of 47·4 months has yielded similar results, with FCR causing a longer overall survival. Moreover, progression-free survival is an accepted and recommended endpoint, since progression was clearly defi ned by the 1996 guidelines and the updated version. We agree that the study population of this trial is young compared with most CLL patients. As stated in the Article, conclusions of this trial could not be transferred to patients with relevant comorbidity. However, patients older than 65 years tolerated both treatment modalities quite well with no signifi cant diff erences in toxic eff ects, since they were selected according to their physical fi tness (cumulative illness rating scale and creatinine clearance).

The Edinburgh congestion charging proposals: The devil in the detail

In 1999, a health impact assessment was carried out as part of the consultation about transport developments in Edinburgh. This recommended adopting the most costly of three options considered, introducing more public transport and reordering the local transport hierarchy so that private car use had lowest priority. The City of Edinburgh Council (CEC) launched a new transport strategy in 2004. Its most significant proposals were plans to reintroduce tramlines in the city and to introduce road user charging. A £2 charge was to be levied once daily when vehicles crossed either of two cordons placed around the city limits and in the city centre. It was promoted as a way to slow down the growth in traffic volume and raise revenue for better public transport. Without a charge and improved public transport services, it was estimated that within 20 years, traffic volume in the city would increase by 50% and congestion would increase by almost 180%. All charging revenue was to be reinvested in transportation improvements, with

‘All singing, all dancing’: staff views on the integration of family planning and genitourinary medicine in Lothian, UK

Background UK policy documents advocate integrated approaches to sexual health service provision to ensure that everyone can access high-quality treatment. However, there is relatively little evidence to demonstrate any resultant benefits. The family planning and genitourinary medicine services in Lothian have been fully integrated and most care is now delivered from a purpose-built sexual health centre. We wished to study the views of staff on integrated sexual and reproductive care. Methods Staff completed anonymous questionnaires before and after integration, looking at four main aspects: the patient pathway, specific patient groups, their own professional status, and their working environment. The surveys used a mixture of five-point Likert-type scales and open-ended questions. Results Over 50% of staff completed the surveys on each occasion. Six months after the new building opened, staff attitudes about the integrated service were mixed. Staff reported more stress and less opportunity for specialisation but there was no change in their sense of professional status or development. There were concerns about how well the integrated service met the needs of specific patient groups, notably women. These concerns co-existed with a verdict that overall service quality was no worse following integration. Conclusions Staff views should form an important part of service redesign and integration projects. Although the results from the Lothian surveys suggest a perceived worsening of some aspects of the service, further evaluation is needed to unpick the different problems that have appeared under the catch-all term of ‘integration’.