Recent headlines have focused on the new executive agency status of Public Health England, responding to the concerns of the profession about independence. Public health influence will also be stronger in the new structures of the NHS, clinical commissioning groups, senates and networks.
All of this is important, but we need to keep asking whether the reforms as a whole will narrow or widen health inequalities. Policy on health inequalities has changed from Labour's emphasis on high-profile targets for Spearhead authorities and performance management to the coalition's reliance on incentives and transparency alongside some new duties.
The recent release of the latest Community Health Profiles contains some interesting insights on the current state of health inequalities. The focus of the last government was on narrowing the gap in life expectancy between the old Spearhead local authorities and the average for England. This ignored the fact that all areas have inequalities in health which should be tackled. The Department's proposed goal to narrow gaps in life expectancy within local authorities is a welcome change.
The profiles can tell us how successfully local authorities have narrowed the gaps in inequalities in their own patch. The headline message is that gaps in life expectancy within an area (known, somewhat opaquely, as the slope index of inequalities) have been getting worse. Between 2001-5 and 2005-9 it grew for both males and females by 0.4 years on average. By 2005-9 the median life expectancy for males in the unhealthiest parts of upper-tier local authorities was 8.8 years lower than for those from the wealthiest areas: for females the difference was 5.9 years. So the inequalities challenge remains huge. This much we knew.
Further analysis shows that there is a lot of variation: 51 per cent of upper tier local authorities saw the gap in life expectancy between the most and least deprived parts of their areas increase for both males and females. While 13 per cent of authorities were doing well, actually narrowing gaps in inequalities for both males and females, in the remaining areas the gap narrowed for one gender while widening for the other. For lower tier local authorities, the proportions that saw widening or narrowing of the gap for both genders were 38 per cent and 14 per cent respectively.
The data also contains some surprises. While Gosport saw the largest increase for males (the gap growing by 4 years), Hackney (not an area associated with inequality reduction in the popular imagination at least) saw the biggest improvement in the country for men (the gap falling by 2.9 years). Some Spearhead areas – the focus of the previous government's health inequalities policy – did well in narrowing inequalities within their areas over the period. Within London Spearheads did as well on average for males as non-Spearheads and slightly better for women. Westminster's gap grew larger than any London Spearhead for males, as did Kingston-upon-Thames for females.
This brief analysis of the Community Health Profiles is based on point estimates and crude averages, ignoring confidence intervals. Despite this it appears to provide potential to support the future of health inequalities policies in three ways.
First, there is rich data out there that will help the Department of Health, Public Health England and health and wellbeing boards to understand how successfully local areas are reducing inequalities within areas. Second, this information may be a useful basis for the proposed health premium. Finally, further analysis could show whether despite missing the inequalities target, the previous government's Spearhead policy was at least starting to hit the point by reducing in area inequalities. Now that sounds like the sort of question that a newly ‘independent’ Public Health England would be well placed to address.