Healthy balance: a review of public health performance and spending

Document type
Corporate author(s)
Audit Commission for Local Authorities and the National Health Service in England
Audit Commission
Date of publication
1 March 2010
Health Services, Social Policy
Social welfare
Material type

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The health of people in England has improved over the past ten years. Life expectancy has increased, infant mortality has fallen. Government targets to cut premature death from heart disease and stroke by 2010 have already been met. But if the big picture is positive, stark problems remain. Inequalities in the health of people from certain areas and social backgrounds has stubbornly resisted improvement, and has even increased in some cases.

A potent measure is the gap between the worst areas and the England average. This is captured in the difference between the England average and performance in the spearhead local strategic partnerships, the one-fifth of areas with the worst rates of deprivation and early death. On that measure, the gap in death rates for both men and women rose between 1998 and 2007 – from 16.1 per cent to 18.6 per cent and from 13.9 to 15.2 per cent respectively. For infant mortality, the gap had begun to narrow and had been on course to meet the government’s target - a 10 per cent reduction by 2010 from a 1998 starting line. But the latest figures show no improvement on the three-year average from 2005 to 2007.

Complex problems such as teenage pregnancy have proved challenging, and new problems have emerged, such as obesity, and problems with alcohol have grown. If today’s trends continue, NHS hospitals in England will admit 1 million patients with alcohol-related conditions in 2011.

There has been no shortage of government policy on these issues, and there has been national action, including, for example, the ban on smoking in public places, but local authorities and primary care trusts, working in combination, have been seen as the main agents. They have been the focus for policy and action as well as the recipients of significant extra money. Health varies according to the wealth and other characteristics of communities. Not surprisingly, progress in tackling problems also varies, yet differences can be striking and beyond what might reasonably be expected.

An example of good practice is Hackney's work in reducing infant mortality. It saw deaths of children under one year fall from a rate of 8.1 per 1,000 live births in 2001-03 to 5.4 in 2005-07, just above the England rate of 4.9. Hackney has an ethnically diverse population, with almost 90 per cent live in an area classified as being in the top five most deprived in England. The national overview of Oneplace assessments linked success with leadership, good information that enables money and activity to be targeted effectively, strong partnership working, and engagement with local communities that draws on and enhances their capacity. But it also showed that proven ways of tackling problems were not consistently adopted and few areas were successfully addressing the causes of inequalities.

Some key points emerge from this briefing. There has been much policy and accompanying guidance, but probably too much and from too many different sources for people in the field to keep up with. PCTs and local authorities have also faced conflicting demands from central government as the research for Giving Children a Healthy Start found. A more consistent and lasting set of policy statements would aid implementation on the ground.

There needs to be more ruthless targeting of money and services and close attention to outcomes. This requires more focus on what is being spent and much sharper evaluation of its impact. Much of this must be done locally. This is why the Commission’s report, Giving Children a Healthy Start included a sample analysis of local spending aimed at improving the health of children that other local areas can follow. We are looking to extend that analysis to spending at ward level and also to provide indicators of the health of young children.

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