An evidence base for tackling inequalities in health: Distraction or necessity?

Disparities in cancer care: perspectives from the front line

OBJECTIVE

The purpose of this qualitative study was to investigate how frontline healthcare professionals witness and understand disparity in cancer care.

METHOD

Six healthcare providers from a range of care settings, none with < 15 years of frontline experience, engaged with researchers in an iterative process of identifying and reflecting on equity and disparity in cancer care. This knowledge exchange began with formal interviews. Thematic analysis of the interviews form the basis of this article.

RESULTS

Participants drew attention to health systems issues, the meaning and experience of discontinuities in care for patients at personal and community levels, and the significance of social supports. Other concerns raised by participants were typical of the literature on healthcare disparities.

SIGNIFICANCE OF RESULTS

Providers at the front lines of care offer a rich source of insight into the operation of disparities, pointing to mechanisms rarely identified in traditional quantitative studies. They are also well positioned to advocate for more equitable care at the local level.

Prioritising public health: a qualitative study of decision making to reduce health inequalities

Background

The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.

Methods

We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.

Results

The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.

Conclusions

It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.

Fault-lines between policy and practice in local partnerships

PURPOSE

The purpose of this study is to explore gaps between policy and practice in relation to the involvement of voluntary and community sector (VCS) members in local strategic partnerships (LSPs), using the example of inequalities in health.

DESIGN/METHODOLOGY/APPROACH

Documentary analysis; semi-structured interviews with VCS representatives from a sample of LSPs in one region of England; semi-structured interviews with key researchers and national stakeholders.

FINDINGS

National policy imperatives to expand the role of the VCS in decision-making and to make LSPs an important avenue for addressing inequalities in health are not always translated into practice. VCS members are at the sharp end of tensions in LSPs between thematic and neighbourhood approaches, local views and strategic priorities and between democratic and participatory approaches to decision-making. Effective engagement in addressing inequalities in health requires a strategic approach across the LSP which is reflected in the priorities of each of the constituent partnerships.

RESEARCH LIMITATIONS/IMPLICATIONS

This is a snapshot of LSPs at one point in time and local interviews are restricted to one region of England.

PRACTICAL IMPLICATIONS

The article illustrates good practice and barriers to VCS involvement in addressing inequalities in health through LSPs. This is relevant to a range of public health partnerships.

ORIGINALITY/VALUE

The views of VCS members on addressing inequalities in health through LSPs have not previously been researched, despite their key role. Lessons are relevant for multi-agency strategic partnerships with a public health focus in England and internationally.