Policy approaches to health inequalitiesin Scotland and EnglandAssessing similarities and differences in post-devolution policy responses to health inequalities Dr Katherine Smith Katherine.Smith@ed.ac.uk Global Public Health Unit, Social Policy School of Social & Political Science University of Edinburgh (ESRC-MRC postdoctoral fellowship, grant number PTA-037-27-0181)
Current concern: The failure of policy efforts to reduce health inequalities in England“Has the English strategy to reduce healthinequalities failed? The importance of this questioncannot easily be overstated. The explicit andsustained commitment of recent Labourgovernments to reduce health inequalities washistorically and internationally unique […]. Theirpolicy initiatives built on decades of public healthresearch, and more often than not were based onempirical evidence which had been collected andsummarized by leading public health experts. Labourstayed in power for an exceptional 13 years, and inWestern democracies it is difficult to imagine alonger window of opportunity for tackling healthinequalities. If this did not work, what will?”(Mackenbach, 2010)
What do we know about post-devolution health policy in Scotland and England? Most analyses focus either on healthcare policies or on specific public health issues (e.g. health inequalities or tobacco control). The story that emerges from this body of work suggests healthcare policies have diverged significantly (e.g. Greer 2005, Bevan 2010, Propper et al 2009, Connolly et al 2010)… … whilst public health policies have remained remarkably similar, despite clear differences in initial intentions/rhetoric (e.g. Cairney, 2009; Smith et al 2009).
Is Scotland Emerging as a UK Public Health Policy Leader? Interviewees across the UK are consistently citing Scotland as a public health policy leader in the UK, following its leadership with smoke- free public places and minimum unit pricing for alcohol. Scotland now appears to have an opportunity to replace its tag as the ‘sick man of Europe’ with a new reputation for health policy innovation (e.g. Smith & Hellowell, 2012).
Yet Policy Approaches to Health Inequalities Remain Remarkably ConsistentAspect of policy approach England ScotlandHow were health inequalities As health gaps resulting from As health gaps resulting fromconceptualised? health deprivation. health deprivation.Commitment to joined-up Yes. Yes.approach?Reference to empirical Yes. Yes.evidence?Targets for reducing health Yes, specific health inequalities Yes, specific health inequalitiesinequalities? targets set in 2001, to be targets set in 2004, to be achieved by 2010. achieved by 2008/2010.How were targets articulated? To reduce health gaps (mainly To improve the health of the between areas). most deprived groups at a particular rate.Where was responsibility for Local NHS bodies (PCTs). Local NHS bodies (Localmeeting health inequalities Health Boards).targets located?
The absence of evidence-based policyin both contexts: Senior academic researcher: ‘The research [on health inequalities] has had absolutely no, well, it’s had very little impact on policies,’ Civil servant (England): ‘My impression is that after about 2001, unfortunately the sheer pace and scale of action required of the Labour government meant that evidence again got pushed onto the back burner […] just because government was producing more policies than it had time to master the evidence on.’ Minister (Scotland): ‘I don’t think there’s very much evidence- based policy around yet.’ Taken from Smith, 2007, 2008.
Comparing the evidence to policy responses for tackling health inequalitiesIdea(s) about health inequalities Are ideas are supported by Are ideas are evident in Labour’s policies? research evidence?Artefact and social selection No NoAccess to health services and Minimally Significantly (esp. from 2004 onwards)treatmentsContextual (place-based) ideas Minimally Significantly (through area-based interventions)Need to change people’s lifestyle- L-Bs are linked to HIs but Significantly (throughout the past decadebehaviours (L-Bs) are usually perceived to be but especially since 2004). symptomatic of more ‘upstream’ causesMaterial-structuralist Yes Significantly evident in policy rhetoric but far more limited with regards to policy actionsPsychosocial and income Significant support References to social capital are evident butinequalities (although some criticisms) reference to income inequalities are absentLifecourse approaches Yes A focus on particular social groups, especially children, is evident but ideas about the ‘lifecourse’ are scarce
1. Policymaking bodies as institutional filters
How Policy Silos Shape the Relationship with ResearchCivil servant (Scotland): ‘People don’t go traipsing through professional journals but you do have specialists within the Department as well. So, for example, on diet and physical activity, there is a Diet Co-ordinator, and there is a Physical Activity Coordinator, who are specialists in their own right… and in addition to that, you have specialists in terms of doctors and things like, many of whom do actually spend a bit of time with the journals.’
2. A lack of belief in alternative ways of organising society
A lack of belief in an alternative way of livingAcademic: ‘I think… a government that isn’t… keen to pursue issues around… income redistribution… you know, that’s a reasonably popular thing to not do. Who wants to pay more taxes? And… if taxes go up for the richest, somehow or other everybody seems to feel they’re being affected by it so, unless the government is prepared to tackle that at a media level, nobody’s going to be unhappy with their decision… not to change taxation.’
3. The lack of institutional memory within policy
The Re-cycling of IdeasAcademic: ‘What’s really struck me […] is we seem to do the same bits of work over and over again, you know? A demand will come for something and because… I don’t keep copies of these things, I think, ‘oh, I think we’ve done that before!’ And then somebody else will dig out… So on Monday, we’re doing a piece of work which I know we did two years ago… But… everybody’s changed so nobody knows that that’s what we did two years ago. […] [And] in the DH they’re now subcontracting a lot of their work… So… somebody, some agency will be given the job of coming up with something-or-other, and it’s like reinventing the wheel - they’ll have no knowledge of what the Department, or allied researchers, has already done. […] So I think that fragmentation, which you’ve got with the normal process of civil servants moving round is becoming intensified because of this process of giving the work to outsiders, who don’t even know what might have happened within the DH.’
Aiming to give ministers ‘what they want’Civil servant (England): ‘If you’ve got a problem, […] the first thing you do is to work back in the files and see what you said last time and then to ask one another what you think we should do and then to make a judgement about what ministers really want, what’s feasible and what’s politically this, that and the other.’ [My emphasis]Former civil servant, Lord Bancroft: ‘seeing that advice which ministers want to hear falls with a joyous note on their ears, and advice which they need to hear falls on their ears with a rather dismal note, [civil servants] will tend to… make their advice what ministers want to hear rather than what they need to hear,’ (quoted in Hennessey 1995, p130).
5. Understanding the decisions health inequalities researchers make
The importance of research funders:Senior academic researcher: ‘[A]cademics are entrepreneurial, they go where the money is and so […] if somebody says, ‘research project on X,’ you know, ‘cycling,’ we’d all start doing sociology of cycling or something, I don’t know [laughs].’Senior academic: ‘[X - name of civil servant who is a personal friend of interviewee], is still amazed that I don’t know things like [policy] initiatives that are going on but then, can understand when I say, you know academics - we go on a need to know basis. […]. If there’s a call for research and there’s some funding, well, we’re learn about that, you know - in twenty-four hours we’ll know about that!’
Intentional influences on research by funders?:Senior academic: ‘I think one of the difficulties is often when there are bids for research funding, it’s almost if the findings or, you know, the messages that are required are stated from the start almost. […] When one looks at research bids, it’s, there are strong steers in terms of what they’re looking for, what kinds of conclusions one’s being steered towards, what kinds of policy messages they want…’
Intentional influences on research by funders:Senior policymaker (Scotland): ‘[T]here is a kind of tension in discussions which go on nowadays between… researchers, who basically say, ‘give us the money - I’ve got a great programme of research here… I can’t tell you too much about it, ‘cause the ideas are just beginning to… So, give me the money - you can trust me and… I’ll produce something. Don’t know what it is but, but something will happen.’ And on the other hand, people like me and […] my colleagues in the MRC, who say, ‘what did we buy for the money?’ And, ‘Well, I know you’re very interested in looking at… health inequalities but actually, I have a problem here - I am required to make policy in this area… at the moment, I have no hard facts at all… and I really would like some research done… and… by the way, I want it done within the next six months and I’ve got that amount of money available for it. So, I want you to give me the best answer you can within six months, given that amount of money.’ And that’s, that’s the real world.’
The Need to Remain Optimistic Most researchers I interviewed wanted to make a difference so many described increasingly focusing on things that they felt could make a small difference.
6. How researchers package messages to policymakers
Deliberate Ambiguity:Academic: ‘When I was at [Blank] I could have been much more… critical. It isn’t simply that I feel the funding source wouldn’t like me to say those things, I actually… would feel it would be a betrayal of the trust that the people who gave me the opportunity to spend my time doing that had in me… and I think, in a way, when I was working at [this organisation] and they are actually funded through [government department], I think… they would have looked at me and said, ‘how can you not have read what is appropriate to say?’ So I think the censoring is actually self- imposed. […] It isn’t that I think they would come the heavy on me, it’s… there’s an unwritten understanding that I won’t rock the boat when I’m writing in that guise. So… at an academic event, I feel I’m me, you know […] I can be much more pointed in the points I want to make… but… I think when I’m writing through a funding source, which is government… and I do out of, and maybe I shouldn’t, I do it out of a sense of loyalty to… the people who are trusting me not to say things that would make them feel uncomfortable… and cast into doubt the judgement that they had in saying I was the right person to do the job.’
Fitting in with perceptions of policypreferencesAcademic: ‘If you have poverty and adversity of that nature, nothing’s gonna save you. Now, they [policy makers] are not gonna like hear that. [Pause] On the other hand, I have to say, I think probably some people have enough clout that we don’t need to… be too tactful. But certainly when I was less experienced and I was putting in for money on [blanked] and health, we did produce papers which were - how can I put it? We weren’t coming out and saying we were absolutely sure that [blank] causes ill-health and there’s no element of selection. We actually found the perfect way through it, which was to say [removed for anonymity]. Now that, I think that’s probably true, actually, but… we were doing it, I was doing it, I was pushing people towards it in order to be clever.’
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