CDE Appendix 1 Literature Review - Central East Local Health ...

The Culture, Diversity and Equity Project: Literature Review
• And fifth, there is a goal for the National Health Service to promote equitable access to services in relation
to need and they’re taking the lead in working with other agencies to tackle the broader determinants of
health. In addition, goals were set for the elimination of health inequalities (Raphael & Bryant, 2006). 20
Limitations and Challenge
Some of the limitations and challenges of UK policies and strategies discussed in the literature are outlined below:
• It has proven difficult to reorientate the health service to focus on health rather than healthcare issues at the
local level. “To achieve this,” Benzeval argues, “local agencies require consistent and clear messages,
reinforced by a range of policy levers such as performance management systems” (2002, p. 212).
• There have been challenges collaborating intersectorally; though reducing health inequalities requires a broad
social policy response, other sectors sometimes have more pressing goals and priorities that may be
fundamentally out of sync with efforts to improve living standards, employment conditions and social security.
Such inconsistencies in priorities can make it difficult to make substantial inroads in reducing health inequities
(Judge & Mackenzie, 2002).
• There have been challenges attributing causes and effects to interventions and policies that are aimed at broad
health determinants and developing appropriate indicators to measure progress on intersectoral initiatives
(Exworthy et al., 2006; WHO, 2008). 21
• There is a less progressive trend in more recent reports (e.g. Wanless 2004; Dept of Health, 2004) to focus more
narrowly on individual health behaviours and healthcare service access issues to the exclusion of broader social
structural determinants of health (Raphael & Bryant, 2006).
• There remains a gap between the state of knowledge and analyses, and the implementation of the latter (Raphael
& Bryant, 2006 )
• Objectives and targets are not always clearly linked and/or articulated (specifically in relation to the Health
Action Zones) and “pathways of expected change” are not always “specified in sufficient detail for it to be
possible to make a reasonable judgement about whether the target is feasible” (Judge & Mackenzie, 2002).
Dominant Framework
• Whole-of-government Health Equity Framework that considers broad socio-economic determinants of health.
20
Raphael & Bryant give the example, in this respect, of “the 2002 Spending Review Public Service Agreement – a kind of business plan –
for the Department of Health which contained the goal ‘By 2010 to reduce inequalities in health outcomes by 10% as measured by infant
mortality and life expectancy at birth’. To facilitate and support action, the government set up ‘cross-cutting spending reviews’ focused
on health inequalities. These reviews are to be used by departments to inform spending plans for the 2003–2006 period.
21 Though it is perhaps too early to judge, there appear to be few visible, attributable impacts of such broad policy interventions in the UK context
thus far, and existing time trends show little evidence of narrowing health gaps (e.g. poverty rates for working aged adults without children reach
all-time high levels by 2002-2003) (Raphael & Bryant, 2006). Exworthy et al. (2006) draw attention to some of the difficulties in measuring
success of such interventions due to the length of time required for such interventions to take effect. As they argue:
the causal pathway between policy and outcome may be apparent only in the long term [years or decades], if at all. …[ Yet] the period in
which the policy interventions are expected to deliver results and over what time periods these effects should be measured often are not
clear” (Exworthy et al., 2006).
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