356. In 2000 the Government set itself the extremely tough target of reducing health inequalities. We commend it for doing so, for setting out so clearly its desire to tackle a notoriously trenchant problem and for establishing an explicit policy framework for doing so.

357. However, the target is unlikely to be met and limited progress has been made to date, even bearing in mind that we would not expect to see quick results. During our inquiry the Government commissioned Professor Sir Michael Marmot to review the evidence and policy in this area with a view to setting a strategic framework for tackling health inequalities for the future, which we welcome.

358. Options for change include abandoning the goal of reducing inequalities as an unachievable goal, recasting the policy framework, or making changes to existing policy and policy-making to increase their chances of success. We do not support the first option; the second option, recasting the entire policy framework, risks further destabilising an area where there have already been too many disruptive changes to policy; so we offer some recommendations for improving existing policy and policy making in this area.

359. This chapter draws together recommendations made previously in this report which aim to improve existing policy and policy making in this area. We first make recommendations about the need to collect evidence about policies and, most importantly, to ensure policies are introduced in ways which permit rigorous evaluation. We then go on to look at a few practical measures the Government should take to improve policy.

Designing and evaluating policy effectively

360. One of the major difficulties, which has beset this inquiry, and indeed is holding back all those involved in trying to tackle health inequalities, is that it is nearly impossible to know what to do given the scarcity of good evidence and good evaluation of current policy. Policy cannot be evidence-based if there is no evidence and evidence cannot be obtained without proper evaluation. As we stated in chapter three, time and again we have heard that policies to tackle health inequalities have been introduced without sufficient thought being given to designing them in a way which enables them to be properly evaluated. While the Government has made attempts at evaluation, these have often been descriptive studies of processes which are not good enough. As a result of these failings, very large sums of money have been spent on initiatives to tackle health inequalities, but we do not know whether they have been effective.

361. Evaluation is an ethical imperative. It is essential to ensure that more public funds are not wasted on imposing ineffective and possibly damaging interventions on already disadvantaged populations. Such waste deprives the community of potentially more productive investments in health and social care which might advantage the poor. Some very simple changes in this area should be adopted. Policies must be designed and implemented in a manner that means they can be evaluated and need to be given sufficient time to yield results before the next set of changes is imposed. Firstly it is essential that all policy innovations are designed with clear definition of their goals and how success will be evaluated. Secondly piloting is essential to determine whether the intervention is sufficiently cost effective to deserve nationwide implementation. We recommend that all future Department of Health policies must, prior to their introduction, demonstrate adherence to the basic set of research guidelines we have detailed in Chapter three, which include:

• piloting
• randomisation and pairing of controls (except where this is impossible);
• collection of adequate baseline data; and
• monitoring and measurement of pre-determined health-related outcomes within a set period of time.

Resource allocation and health inequalities

363. The Department of Health is responsible for allocating resources to the NHS As we showed in chapter four, the resource allocation model used by the Government seeks to equalise the funding available to PCTs in relation to proxies for need, and has had a major effect on the funding PCTs receive; in 2009-10, the neediest PCTs are to receive almost 70% more money per head than the least needy. However, many PCTs have not yet received their full needs-based allocations. The Government must move more quickly to ensure PCTs receive their real target allocations.

364. Trade offs exist between redistribution of health resources to tackle health inequalities, and the NICE model of distribution, based on investing in the most cost-effective treatment for the whole populations. These trade offs have never been explicitly articulated and examined and we recommend that they should be. There needs to be a wide debate about the public willingness to shift resources to those socio-economic groups with the poorest health.

365. In addition, as we have recommended previously, more needs to be known about the treatments and services which are displaced to fund the new treatments recommended by NICE. A first step in this process would be to assess the added cost of NICE guidance on each PCT in England—research which we recommend the Government should fund immediately.

366. The Government must also track the money which is spent to tackle health inequalities and what it is spent on, both funds specifically allocated for health inequalities initiatives, and mainstream funding that is directed towards this. As a useful first step the Department of Health should commission an in-depth study in a small sample of PCTs.

Specific health inequalities initiatives

367. The Government has introduced specific policies to tackle health inequalities. As we saw in chapter five, two of particular importance were establishing:

• Health inequalities targets; and
• Surestart.

TARGETS

368. In aiming to reduce health inequalities by 10% in ten years, the Government has introduced a target which is arguably the toughest anywhere in the world, and which has received international plaudits. Despite the likelihood that the target will be missed, we believe that aspirational targets such as this can prove a useful catalyst to improvement, and we therefore recommend that the commitment be reiterated for the next ten years.

369. However, there remain significant problems with the data used to monitor progress against this target. The infant mortality aspect of the target does present difficulties. There are now so few infant deaths in each spearhead area that comparing infant mortality between these areas has severe limitations. We recommend that the Government review the infant mortality component of the health inequalities target and replace it with a more meaningful measure.

370. Health inequalities have many facets—health is unequal according not only to social class, but to gender, ethnicity, disability and mental health status, to name only a few. There is concern that the elderly receive worse treatment. It is crucial that the Government's focus on socio-economic inequalities alone does not lead to other aspects of health inequalities going unnoticed and ignored. We were pleased to see that some local areas already focus on health inequalities related to ethnicity as appropriate to their local populations; however there is little to suggest that health inequalities relating to age, gender, disability or mental health status are even being adequately measured let alone addressed, and we recommend that the Government rectify this.

SURE START, CHILDREN'S CENTRES AND THE EARLY YEARS

371. We commend the Government for taking positive steps to place early years at the heart of policy to address health inequalities through Sure Start. As we have already discussed, many witnesses were very positive about the benefits of Sure Start. National evaluation shows that it has enjoyed some success, however, we must sound a note of caution that Sure Start has still has not demonstrated significant improvements in health outcomes or health inequalities for either children or parents. This policy, originally introduced to specifically target those in deprived areas, is now being extended, without any prior piloting, to all areas of the country regardless of level of deprivation. It is absolutely essential that early years interventions remain focused on those children living in the most deprived circumstances, and the impact of Children's Centres must be rigorously monitored.

The role of the NHS in tackling health inequalities

372. The NHS has the capacity to tackle health inequalities by providing excellent services targeted at, and accessible to those that need them. Chapter X considered a number of ways this might best be done.

EFFECTIVE INTERVENTIONS

373. Treatment, screening, and interventions to change health behaviours are the key tools available to the NHS for tackling health inequalities. Whilst evidence exists to support the clinical effectiveness of some interventions, such as prescribing of antihypertensive and cholesterol-reducing drugs, less is known about their cost effectiveness, and in particular about how to ensure they are targeted towards those in the lowest socio-economic groups so that they actually have an impact on health inequalities. The Government is to introduce vascular checks; we urge it to do so with great care, and according to the steps outlined in chapter three, so that it does not waste another crucial opportunity to rigorously evaluate the effectiveness and cost effectiveness of this screening programme.

374. Getting people to adopt a healthy lifestyle is widely acknowledged to be difficult, and evidence suggests that traditional public information campaigns are not successful with lower socio-economic or other hard-to-reach groups—in fact we were told that these interventions can actually widen health inequalities because richer groups respond better to health promotion messages. Social marketing is heralded as an approach that allows messages to be communicated in more tailored and evidence based ways. We have not seen firm evidence to support this claim, and we recommend that social marketing interventions are evaluated to ascertain their success. There is sound evidence to support brief, opportunistic interventions in primary and secondary care, such as advice from GPs to give up smoking, followed by referral to more specialist health promotion services. However further steps are needed to ensure that the most heavily addicted smokers, who are often those from the lowest socio-economic groups, benefit fully from these interventions.

PRIMARY CARE SERVICES

375. Primary care services are at the frontline of tackling health inequalities; we received many suggestions for additions to the QOF points system. It is clear that the QOF needs radical revision to fully take account of health inequalities, and we therefore recommend that tackling health inequalities should be an explicit objective during annual QOF negotiations. In particular, the QOF needs to provide more incentives to stop smoking. However, additions to the QOF may be costly and this can only be done if other things are removed.

SECONDARY AND SPECIALIST SERVICES

376. Primary care is the chief target of most efforts to tackle health inequalities through improving NHS services; however, in solely focusing on this, there is a real risk that inequalities in other NHS services will persist, and that the great opportunities which exist throughout in secondary care and specialised services to tackle inequalities will be missed. We recommend that the role of secondary care in tackling health inequalities should be specifically considered by Professor Sir Michael Marmot's forthcoming review, and this should include consideration of including tackling health inequalities as part of the Payment by Results framework and/ or the Standards for Better Health.

NHS EARLY YEARS SERVICES—HEALTH VISITING AND MIDWIFERY

377. We have been told repeatedly that the early years offer a crucial opportunity to 'nip in the bud' health inequalities that will otherwise become entrenched and last a lifetime. While there is little evidence about the cost-effectiveness of current early years services, it seems odd that numbers of health visitors and midwives are falling, and members of both those professions report finding themselves increasingly unable to provide the health promotion services needed by the poorest families, at the same time as the Government reiterates its commitments to early-years' services. The Department must undertake research to find out the consequences of the decline in numbers of health visitors and midwives and to consider whether some aspects of the health promotion role played by midwives and health visitors could be effectively done by other types of staff.

PCTS AND SHAS

378. PCTs and SHAs should play a central role in informing and co-ordinating efforts to tackle health inequalities. However, our evidence has not suggested that they are currently providing the leadership that might be expected of them.

Tackling health inequalities across other sectors and departments

379. Many of the causes of health inequalities are outside the direct areas of health and health policy, the NHS and the Department of Health still have a valuable role to play in providing leadership across all sectors and government departments to promote joined up working to tackle health inequalities. As we set out in chapter seven, criteria need to be established by which their success in doing this is systematically and explicitly evaluated, possibly by adding this to the Cabinet Office reviews of the performance of Whitehall Departments.

COOKERY AND NUTRITION IN SCHOOLS

380. We welcome recent improvements in school meals and the introduction of compulsory cookery lessons, but we remain concerned about low rates of school meal take-up, and also about the lack of any data about whether the poorest children are benefiting from a healthy meal. We recommend that the Government closely monitors take-up of school meals and analyses this by socio-economic group. We also recommend that free ingredients should be provided for all school cookery lessons; it is unlikely that all children will bring the ingredients with them.

FOOD LABELLING

381. We are appalled that, four years after we first recommended it, the Government and FSA are continuing to procrastinate about the introduction of traffic-light labelling to make the nutritional content of food clearly comprehensible to all. In the light of resistance by industry, and given the urgency of this problem, we recommend that the Government legislate to introduce a statutory traffic light labelling system. A traffic light labelling system should also be introduced for all food sold in takeaway food outlets as well; currently food purchased from such outlets, despite often being very high calorie, does not have any nutritional labelling at all. The Government should consider the best ways of providing information about the nutritional content of food bought from restaurants.

HEALTH PROMOTION IN SCHOOLS

382. We were told by the DCSF of several apparently 'successful' initiatives to provide wider health and social support in schools, such as the Extended Schools and Healthy Schools initiatives. However to date there has been no evaluation of the impact of these programmes on health or health inequalities. If the Government wishes to claim that it is actively engaged in the health inequalities agenda, it must be prepared to back this up with hard evidence of whether its policies are actually influencing health outcomes, together with information on their costs and cost effectiveness. We recommend that the Department of Health and DCSF collaborate to produce quantitative indicators and to set targets for the Healthy Schools programme.

THE BUILT ENVIRONMENT

383. The built environment affects every aspect of our lives. During the inquiry we heard many concerns: high streets awash with fast food outlets, flagship health centres located 'at random' and planning policies which have created towns and cities dominated by the car, with out-of-town supermarkets and hospitals, which have discouraged walking and cycling. In our view, health must be a primary consideration in planning decisions. To ensure that this happens, we recommend

• The publication of a Planning Policy Statement on health, which should encourage walking and cycling and enable local planning authorities to restrict the number of fast food outlets
• that PCTs should be made statutory consultees for local planning procedures;

TOBACCO CONTROL

384. Smoking remains one of the biggest causes of health inequalities; we welcome both the Government's ban on smoking in public places, and its intention to ban point of sale tobacco advertising, as evidence indicates that both of these measures may have a positive impact on health inequalities. Unfortunately, tobacco smuggling, by offering smokers half price cigarettes, negates the positive impact of pricing and taxation policies. Tobacco smuggling has a disproportionate impact on the poor, particularly young smokers. Some progress has been made in this area but not enough; there has been no progress at all in reducing the market-share of smuggled hand-rolled tobacco, which is smoked almost exclusively by those in lower socio-economic groups. We recommend the reinstatement of tough targets and careful monitoring of them following the transfer of this crucial job has passed to UKBA, to ensure that it remains a sufficiently high priority. We also recommend that the UK signs up to the agreements to control supply with the tobacco companies Philip Morris International and Japan Tobacco International as a matter of urgency.