Framing health inequalities for local intervention:

comparative case studies

Tim Blackman 1 , Barbara Harrington

1 , Eva Elliott

2 ,

Alex Greene 3 , David J. Hunter

1 , Linda Marks

1 , Lorna

McKee 3 , and Gareth Williams

2

1Wolfson Research Institute, Durham University 2School of Social Sciences, Cardiff University 3Health 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

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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, Schön 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

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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 ex- mining ⁄ 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 organisations built up from the data from respondents, localities built up from the organisational profiles, and countries built up from the locality profiles. These revealed patterns of similarity and difference by role, type of organisation, 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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in March 2009, to which all participating organisations 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 Schön 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 analysing and knowing, arguing and acting. Through the process, ill-defined, often amorphous situations can be understood and dealt with … (F)rames 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 summarised 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, Labour 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 reorganisations 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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T ab

le 1.

A lt er na ti ve

fr am

in gs

of he al th

in eq ua li ti es

in se le ct ed

lo ca li ti es

of E ng la nd , S co tl an d an d W al es , 20 06 -2 00 8

P o li ti ca l fr a m in g

A u d it fr a m in g

E vi d en ce

fr a m in g

T re a tm

en t fr a m in g

E n g la n d

H ig h p ri o ri ty

to n a rr o w in g th e g a p

b et w ee n a re a s in it ia ll y ec li p se d b y

p re ss u re

to re d u ce

h o sp it a l w a it in g

ti m es

a n d b u d g et

d efi ci ts , a n d

im p ed ed

b y re o rg a n is a ti o n s. H ea lt h

in eq u a li ti es

in cr ea si n g ly

co n st ru ct ed

a s a h ea lt h ca re

is su e o f ea rl ie r

d ia g n o si s a n d tr ea tm

en t.

H ea lt h in eq u a li ti es

fr a m ed

a s

n a ti o n a l a n d lo ca l ta rg et s,

p ro m o ti n g lo ca l a ct io n a n d ri si n g

sp en d in g , w it h st re n g th en in g fo cu s

o n ro le

o f N H S se rv ic es

in m a k in g

sh o rt

te rm

g a in s. F a il u re

to a ch ie v e

ta rg et s n o t a h ig h st a k es

is su e.

E v id en ce -b a se d fr a m in g s

in cr ea si n g ly

d o m in a te d b y

tr ea tm

en t m o d el

o f in te rv en ti o n

a n d w ea k w it h re g a rd

to so ci a l

d et er m in a n ts

a n d li fe st y le

in te rv en ti o n s w h ic h la ck

ca u sa l

m o d el li n g .

Im p er a ti v e fo r p er fo rm

a n ce

in d ic a to rs

to sh o w

p ro g re ss

a g a in st

ta rg et s b ia se s a ct io n to

ea rl y

d et ec ti o n a n d m ed ic a ti o n , w h er e

th er e a re

si g n ifi ca n t sp en d in g

in cr ea se s re p o rt ed .

S co tl a n d

S tr en g th en in g p ri o ri ty

to im

p ro v e

h ea lt h in

th e m o st

d is a d v a n ta g ed

a re a s, w it h sh a re d co m m it m en t a n d

st a b le

re la ti o n sh ip s a cr o ss

lo ca l

g o v er n m en t a n d N H S p a rt n er sh ip s

a n d le v el s o f g o v er n m en t, a n d

st ro n g a ck n o w le d g em

en t o f so ci a l

d et er m in a n ts .

T a rg et s fo r h ea lt h im

p ro v em

en t a re

n o t st ro n g fr a m in g s, w it h em

p h a si s

o n lo ca l in n o v a ti o n a n d ev a lu a ti o n

o f w h a t w o rk s, a n d a cc ep ta n ce

o f

lo n g ti m e sp a n s fo r ch a n g e to

o cc u r. F a il u re

to a ch ie v e ta rg et s

n o t a h ig h st a k es

is su e.

E v id en ce -b a se d fr a m in g s

st re n g th en , m a in ly

a s a n ev a lu a ti v e

a p p ro a ch

to li fe st y le

in te rv en ti o n s,

b u t ex p ec te d lo n g -t er m

g a in s to o

in ta n g ib le

to a ff ec t sp en d in g

si g n ifi ca n tl y ,

T re a tm

en t m o d el

su b o rd in a te

to em

p h a si s o n li v in g co n d it io n s a n d

li fe st y le s, b u t n o t p er ce iv ed

a s

re fl ec te d in

si g n ifi ca n t sp en d in g

in cr ea se s b ec a u se

o f th e d if fi cu lt y

o f m a k in g a fi n a n ci a l ca se .

W a le s

W ea k en in g p ri o ri ty

a ft er

so ci a l

d et er m in a n ts

d is co u rs e is ec li p se d

b y m ed ia -f u el le d p re o cc u p a ti o n

w it h a cu te

se rv ic es

a n d w a it in g

ti m es

a n d p o li ti ca ll y d a m a g in g

co m p a ri so n s w it h E n g la n d . H ea lt h

in eq u a li ti es

in cr ea si n g ly

co n st ru ct ed

a s is su es

o f li fe st y le

a s w el l a s

a cc es s to

ca re .

L o ca l d el iv er y o f st a n d a rd s w it h n o

co n n ec ti o n to

n a ti o n a l ta rg et s o r

n a ti o n a l p er fo rm

a n ce

a ss es sm

en t.

H ea lt h in eq u a li ti es

n o t u n iv er sa ll y

a n o p er a ti o n a l o r sp en d in g p ri o ri ty

lo ca ll y b ey o n d a cc es s is su es . H ea lt h

a g en d a m o re

d ri v en

b y w a it in g

ti m e ta rg et s.

E v id en ce

a v a il a b le

fr o m

ev a lu a ti o n s b u t o v er sh a d o w ed

b y

h o sp it a ls a n d th ei r sp en d in g n ee d s.

H ea lt h p ro b le m s fr a m ed

a s a

le g a cy

o f p a st

h ea v y in d u st ry .

N o sy st em

a ti c a d d re ss in g o f h ea lt h

in eq u a li ti es

lo ca ll y . P re o cc u p a ti o n

in d ep ri v ed

a re a s is w it h a cc es s to

tr ea tm

en t.

Framing health inequalities 53

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Structural change and reorganisation 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 reorganisations 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 prioritise public health and tackle health inequalities. Local partnerships were widely regarded as working well and relationships between individuals across organisations 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 Labour and Plaid Cymru coming to power in June 2007, some felt that the issue had become even more eclipsed than under a Labour 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, centralising 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 emphasising wider determinants rather than individual behaviour change: ‘addressing aspects of poverty such as improving people’s employability, increasing young people’s confidence and skills and regenerating the most disadvantaged neighbourhoods’, also on the basis of setting targets to increase the rate of health improvement (NHS Scotland 2005: 22). In Wales, in a gradual

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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 prioritising public health. Moreover, discussions about health improvement were increasingly framed in terms of behaviour 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 modernising services and improving access to care, while also addressing behaviour 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, Labour 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 unfavourably 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