Performance Assessment and Wicked Issues: The Case of Health Inequalities
Lead Research Organisation:
Durham University
Department Name: School of Applied Social Sciences
Abstract
Abstracts are not currently available in GtR for all funded research. This is normally because the abstract was not required at the time of proposal submission, but may be because it included sensitive information such as personal details.
Organisations
Publications
Blackman T
(2012)
Framing health inequalities for local intervention: comparative case studies.
in Sociology of health & illness
Blackman T
(2010)
Wicked Comparisons: Reflections on Cross-national Research about Health Inequalities in the UK
in Evaluation
Blackman TJ
(2014)
Austerity and health.
in Maturitas
| Description | Tackling socio-economic inequalities in morbidity, mortality and access to care have been recognised by most European countries as a policy priority. However, health inequalities have an intractability shared with other 'wicked issues': complex problems that can be defined in different ways, often change and take different forms, and have many causal levels. This makes such issues difficult to incorporate into the widespread growth of performance assessment as a method of driving the implementation of policy objectives - because establishing targets, metrics and accountability is problematic when the problem has the complexity of a wicked issue. This was the main focus of our study. The UK presents an interesting opportunity to compare national approaches to tackling health inequalities because although there is one National Health Service (NHS) there are different policies and structures for the NHS and other local public services in each of the UK's four countries. This is especially the case with regard to performance assessment, and we therefore chose to design the study by comparing England, Scotland and Wales (Northern Ireland was not included in this study because at inception its regional government was suspended). Spending on the NHS varies across these countries but shows little relationship with health outcomes or service performance. Each country also presents a different policy context, especially with regard to the extent to which health inequalities have been incorporated into performance assessment systems. England has been characterised as a top-down performance assessment regime where targets and competition are used as the dominant approaches to delivery. Scotland is often said to have a tradition of politicians accepting the professional leadership of public services, with less competitive pressure and a more collaborative approach to performance assessment. Wales (until recently) has had a much more locally-focused organisation of health services, with less direct performance assessment by national government. The study set out to understand how these contrasting policy contexts are reflected in the ways local actors conceptualise and devise strategies to tackle health inequalities. Two hundred interviews with actors holding strategic and managerial responsibilities in the NHS, local government and local partnerships were interviewed in two phases (2006 and 2008). The interviews were carried out in regional centres and ex-mining/industrial hinterland areas to achieve some comparability of context and health status. All the localities had rising trends for male and female life expectancy, but there were differences in the extent to which inequalities were changing. Scotland clearly faced the biggest challenge, with its average life expectancy trailing behind both England and Wales, but with this lower national average making it no easier for the most deprived areas to close their gaps with it. England was the first of the three countries to adopt targets for narrowing health inequalities in 2001, and these were initially mandatory for the local NHS organisations responsible for commissioning health services (PCTs) in areas with the worst health and deprivation. Scotland adopted health inequality targets in 2004, aimed at health improvements in the most deprived areas, and requiring the local health boards to report annually to the Scottish government. Wales also adopted health inequality targets in 2004, aimed at a more rapid reduction in mortality among the most deprived groups compared to the national average. These were not quantified or subject to performance assessments. In England and Scotland, national policy was clearly perceived by our interviewees as concerned with narrowing health inequalities, while this was much less the case in Wales, despite national policy documents in all three countries including commitments to tackle the issue. The more systematic measurement of progress that was in place in England - because of more extensive standard metrics linked to the national targets - made little difference to how local actors talked about health inequality compared to Scotland. Indeed, performance reporting using these metrics was somewhat detached from interventions and any modelling of their effects, although in England there was evidence from the more recent interviews of a local emphasis on finding people at risk and treating them early with drugs. This was a strategy believed to be deliverable on a large scale with clear cause-effect results, unlike other 'wider determinant' strategies such as housing improvements and job creation where health gain was more uncertain and long term. In all three countries there was a theme of how difficult it was to prioritise spending on health inequality when pay-backs were hard to identify over the short term. The priority given to work on health inequalities in England and Scotland was said in large measure to depend on having higher political priorities under control, especially waiting times for treatment. This was a major theme, and one that points to the vulnerability of work on health inequalities in the current financial crisis. Welsh policy had an emphasis on equity that skewed attention to access issues like waiting times, but health inequality - inequalities in outcomes rather than access to care - had little specific focus beyond local joint health strategies that were often regarded as too general. The main way that health inequalities entered into local discourse in Wales was the burden of poor health left by the legacy of past heavy industry and long-term illness, calling for a particular a focus on chronic disease management rather than an issue of benchmarking one area's health status against another, which was regarded as an English approach. Overall, performance assessment made a difference to how narrowing health inequality as a policy for implementation was conceptualised locally and the attention it received. While the fact that performance assessment in Wales did not include health inequalities biased local priorities towards other matters, the fact that it did in England meant that local actors were aware of their 'gap' but were not taking actions that were radically different. In particular, in none of our localities did we find any clear link between performance assessment and systematic learning from the interventions being pursued. There is, therefore, a major challenge to transform systems of accountability into systems for learning and systematically embedding that learning in practice. |
| Exploitation Route | Development of health improvement strategies and cross-governmental knowledge exchange within the UK. |
| Sectors | Communities and Social Services/Policy,Education,Healthcare,Government, Democracy and Justice |
| URL | http://www.publicservices.ac.uk/index.php/research/performance-assessment-and-wicked-issues-the-case-of-health-inequalities |
| Description | Conference presentations include the 2008 and 2009 UK Public Health Association Annual Forums (widely attended by practitioners); the Local Authority Research Council Initiative (LARCI) performance management seminar in 2006; the 2006 Public Administration Committee (PAC) annual conference; the ESRC/National Audit Office Public Services Programme seminar in 2006; and the ESRC Public Services Programme 'showcase event' in 2006. The project's advisory group was an important means of dissemination. It was chaired by Sir Derek Wanless and included representatives from the Scottish and Welsh Governments and the Department of Health. All spoke at the project's dissemination conference held in Durham on 30 March 2009. This was a very successful event attended by participants from the NHS, local government and universities across England, Scotland and Wales. The proceedings informed the project's final journal article submitted to Social Science & Medicine. This paper was requested by the Department of Health for circulation among policy leads. Prof Blackman was invited to participate in a Guardian Public Roundtable. The project's results were presented at the ESRC Public Services Programme End of Programme Event on 11 December 2009 in the QEII Conference Centre, Westminster, which has the title 'Public Services in the 2010s: Prosperity, Austerity and Recovery'. It combined a poster show and displays of publications with panels and round tables, included contributions from Sir Gus O'Donnell (UK Cabinet Secretary) and Martin Weale (Director of the National Institute of Economic and Social Research) as well as programme researchers and other experts on public services. The Chair of our Advisory Group, Derek Wanless, also attended. A paper summarising the results was sent to all the senior staff in the NHS, local government and partnership organisations that participated in the study, with an invitation to attend the March 2009 dissemination conference (the invitation was also extended to other organisations). Several discussions followed from this but unfortunately our ethics protocol prevents us from revealing identities because all participants were guaranteed anonymity in the study (a condition of our NHS ethics approval). The Welsh Assembly Government took a strong interest in the findings and what they revealed about local perspectives on national policy. This was used to inform taking forward the Government's health inequalities agenda. Results from the project were also discussed with the UK Prime Minister's Head of Strategy; the Institute for Public Policy Research; the Department of Health's Health Inequalities Unit; and the National Support Team for Health Inequalities. |
| First Year Of Impact | 2006 |
| Sector | Communities and Social Services/Policy,Education,Healthcare,Government, Democracy and Justice |
| Impact Types | Policy & public services |